Federal Agency U.S. Department of Health and Human Services Criteria 2 CFR section 200.303 requires that non-federal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Additionally, 2 CFR section 200.510 requires the auditee to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total federal awards expended as determined in accordance with 2 CFR section 200.502. Condition and Context In preparing the SEFA, Nemours management adjusted general ledger amounts for payroll adjustments recorded in the general ledger in fiscal year 2024 that related to fiscal year 2023 expenditures. These manual adjustments, were not material to the 2023 combined financial statements and related to correcting allocations of time and effort charged to federal grants. Through our allowability testing of payroll expenditures within the Research & Development Cluster, we determined the impact of these time and effort payroll corrections was not completely captured during the SEFA preparation process. As a result, adjustments to the SEFA were made of approximately $617,000. Possible Cause and Effect Because effort reporting changes were not timely identified and processed prior to the closing of the books and records for the fiscal year, there were payroll related changes impacting federal grants that were processed in the general ledger during 2024. As a result, management attempted to identify all of these changes and manually adjust the SEFA accordingly. Due to the manual nature of the process, a portion of the 2024 corrections which impacted the 2023 expenditures were not completely captured during the SEFA preparation process. Questioned Costs None Statistically Valid Sample Not applicable Repeat of Prior Finding No Recommendations Management should revise its process to ensure that effort reporting changes are timely identified and processed in the appropriate period. Additionally, should changes be identified subsequent to year end, the process to identify manual adjustments to the SEFA, if any, should be reviewed for completeness. View of Responsible Officials Management agrees with the noted finding. Management notes that all payroll adjustments were completed prior to reporting any final costs to the funding agencies.
Federal Agency U.S. Department of Health and Human Services Criteria 2 CFR section 200.303 requires that non-federal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Additionally, 2 CFR section 200.510 requires the auditee to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total federal awards expended as determined in accordance with 2 CFR section 200.502. Condition and Context In preparing the SEFA, Nemours management adjusted general ledger amounts for payroll adjustments recorded in the general ledger in fiscal year 2024 that related to fiscal year 2023 expenditures. These manual adjustments, were not material to the 2023 combined financial statements and related to correcting allocations of time and effort charged to federal grants. Through our allowability testing of payroll expenditures within the Research & Development Cluster, we determined the impact of these time and effort payroll corrections was not completely captured during the SEFA preparation process. As a result, adjustments to the SEFA were made of approximately $617,000. Possible Cause and Effect Because effort reporting changes were not timely identified and processed prior to the closing of the books and records for the fiscal year, there were payroll related changes impacting federal grants that were processed in the general ledger during 2024. As a result, management attempted to identify all of these changes and manually adjust the SEFA accordingly. Due to the manual nature of the process, a portion of the 2024 corrections which impacted the 2023 expenditures were not completely captured during the SEFA preparation process. Questioned Costs None Statistically Valid Sample Not applicable Repeat of Prior Finding No Recommendations Management should revise its process to ensure that effort reporting changes are timely identified and processed in the appropriate period. Additionally, should changes be identified subsequent to year end, the process to identify manual adjustments to the SEFA, if any, should be reviewed for completeness. View of Responsible Officials Management agrees with the noted finding. Management notes that all payroll adjustments were completed prior to reporting any final costs to the funding agencies.
2023-002 Material Weakness – Preparation of Schedule of Expenditures of Federal and State Awards (“SEFSA”) Statement Condition: Under Uniform Guidance 2 CFR Section 200.508 reporting compliance, it is the auditee’s responsibility to prepare the Schedule of Expenditures of Federal and State Awards statement. The Uniform Guidance 2 CFR Section 200.502 requires the proper tracking and accounting of federal expenditures incurred under the same basis of accounting as the basic financial statements to ensure proper cut-off and timely reporting to the Federal Audit Clearinghouse. Criteria: Procedures should be in place to create a materially accurate Schedule of Expenditures of Federal and State awards statement based on the cash basis of accounting specifically tracking expenses when they are paid. Cause: The procedures in place did not create a materially accurate Schedule of Expenditures of Federal and State awards financial statement for major program compliance. For CFDA #66.458, the SEFSA provided by the Authority did not represent expenditures as paid. This was a result of the bifurcation between loan and grant disbursements, as well as presentation of loan balances on the SEFSA. Uniform Guidance states that SEFSA loan balances should be reported as prior year outstanding loan balance plus current year borrowings. Effect: The fund used to track the expenditures did not properly reflect the federal expenditures incurred in 2023. Recommendation: Procedures should be implemented to create a materially accurate Schedule of Expenditures of Federal and State award financial statement, which should include ascertaining between loan and grant expenditures, and understanding the process for reporting loan balances on the SEFSA. Views of Responsible Officials and Planned Corrective Actions: In order to create a materially accurate Schedule of Expenditures of Federal and State award financial statement, the Authority will establish procedures to ascertain loan and grant expenditures, as well as taking into account the Uniform Guidance requirement for presenting loan balances on the SEFSA.
2023-002 Material Weakness – Preparation of Schedule of Expenditures of Federal and State Awards (“SEFSA”) Statement Condition: Under Uniform Guidance 2 CFR Section 200.508 reporting compliance, it is the auditee’s responsibility to prepare the Schedule of Expenditures of Federal and State Awards statement. The Uniform Guidance 2 CFR Section 200.502 requires the proper tracking and accounting of federal expenditures incurred under the same basis of accounting as the basic financial statements to ensure proper cut-off and timely reporting to the Federal Audit Clearinghouse. Criteria: Procedures should be in place to create a materially accurate Schedule of Expenditures of Federal and State awards statement based on the cash basis of accounting specifically tracking expenses when they are paid. Cause: The procedures in place did not create a materially accurate Schedule of Expenditures of Federal and State awards financial statement for major program compliance. For CFDA #66.458, the SEFSA provided by the Authority did not represent expenditures as paid. This was a result of the bifurcation between loan and grant disbursements, as well as presentation of loan balances on the SEFSA. Uniform Guidance states that SEFSA loan balances should be reported as prior year outstanding loan balance plus current year borrowings. Effect: The fund used to track the expenditures did not properly reflect the federal expenditures incurred in 2023. Recommendation: Procedures should be implemented to create a materially accurate Schedule of Expenditures of Federal and State award financial statement, which should include ascertaining between loan and grant expenditures, and understanding the process for reporting loan balances on the SEFSA. Views of Responsible Officials and Planned Corrective Actions: In order to create a materially accurate Schedule of Expenditures of Federal and State award financial statement, the Authority will establish procedures to ascertain loan and grant expenditures, as well as taking into account the Uniform Guidance requirement for presenting loan balances on the SEFSA.
2023-004 – Schedule of Expenditures of Federal Awards Federal program information: Funding Agency: All major program funding agencies Title: All major programs Assistance Listing Number: All major program ALN’s Award Periods: All major program award periods Criteria: 2 CFR section 200.510 (b), requires the Department to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the Department’s financial statements and the SEFA must include the total awards expended as determined in accordance with 2 CFR §200.502. Condition: Certain federal programs on the SEFA had inaccurate Assistance Listing Numbers (ALN) and/or ALN’s were not included on the initial client prepared SEFA. In addition, several audit adjustments were needed to correct the expenditures reported on the SEFA. Lastly, significant adjustments were needed to correct the ending and beginning receivable/unearned revenue balances. Context: N/A Questioned Costs: None. Cause: Internal controls were not designed and implemented to ensure accurate preparation of the SEFA. Effect: Revisions were needed to accurately prepare the SEFA by ALN and to ensure expenditures and receivable/unearned revenue balances were properly reported. Without proper internal controls there is the risk that errors and misstatements could exist and not be prevented or detected and corrected on a timely basis. Auditors’ Recommendation: Internal control procedures should be established to ensure that an accurate SEFA is prepared in accordance with 2 CFR §200.502. The SEFA should be reviewed by someone independent from the preparer to verify the accuracy of the information. Management Response: The Department will work with their accounting consultant to properly prepare the SEFA. The Department will verify all Assistance Listing Numbers and make all necessary adjustments prior to submitting the SEFA to the auditors.
2023-004 – Schedule of Expenditures of Federal Awards Federal program information: Funding Agency: All major program funding agencies Title: All major programs Assistance Listing Number: All major program ALN’s Award Periods: All major program award periods Criteria: 2 CFR section 200.510 (b), requires the Department to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the Department’s financial statements and the SEFA must include the total awards expended as determined in accordance with 2 CFR §200.502. Condition: Certain federal programs on the SEFA had inaccurate Assistance Listing Numbers (ALN) and/or ALN’s were not included on the initial client prepared SEFA. In addition, several audit adjustments were needed to correct the expenditures reported on the SEFA. Lastly, significant adjustments were needed to correct the ending and beginning receivable/unearned revenue balances. Context: N/A Questioned Costs: None. Cause: Internal controls were not designed and implemented to ensure accurate preparation of the SEFA. Effect: Revisions were needed to accurately prepare the SEFA by ALN and to ensure expenditures and receivable/unearned revenue balances were properly reported. Without proper internal controls there is the risk that errors and misstatements could exist and not be prevented or detected and corrected on a timely basis. Auditors’ Recommendation: Internal control procedures should be established to ensure that an accurate SEFA is prepared in accordance with 2 CFR §200.502. The SEFA should be reviewed by someone independent from the preparer to verify the accuracy of the information. Management Response: The Department will work with their accounting consultant to properly prepare the SEFA. The Department will verify all Assistance Listing Numbers and make all necessary adjustments prior to submitting the SEFA to the auditors.
2023-004 – Schedule of Expenditures of Federal Awards Federal program information: Funding Agency: All major program funding agencies Title: All major programs Assistance Listing Number: All major program ALN’s Award Periods: All major program award periods Criteria: 2 CFR section 200.510 (b), requires the Department to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the Department’s financial statements and the SEFA must include the total awards expended as determined in accordance with 2 CFR §200.502. Condition: Certain federal programs on the SEFA had inaccurate Assistance Listing Numbers (ALN) and/or ALN’s were not included on the initial client prepared SEFA. In addition, several audit adjustments were needed to correct the expenditures reported on the SEFA. Lastly, significant adjustments were needed to correct the ending and beginning receivable/unearned revenue balances. Context: N/A Questioned Costs: None. Cause: Internal controls were not designed and implemented to ensure accurate preparation of the SEFA. Effect: Revisions were needed to accurately prepare the SEFA by ALN and to ensure expenditures and receivable/unearned revenue balances were properly reported. Without proper internal controls there is the risk that errors and misstatements could exist and not be prevented or detected and corrected on a timely basis. Auditors’ Recommendation: Internal control procedures should be established to ensure that an accurate SEFA is prepared in accordance with 2 CFR §200.502. The SEFA should be reviewed by someone independent from the preparer to verify the accuracy of the information. Management Response: The Department will work with their accounting consultant to properly prepare the SEFA. The Department will verify all Assistance Listing Numbers and make all necessary adjustments prior to submitting the SEFA to the auditors.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Criteria Part 2, CFR 200, 200.510 states “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Section 200.502 notes “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs.” Condition Incorrect expenditure amounts were reported as expenditures for multiple Federal awards. Incorrect, or inconsistent Assistance Listing numbers were used for Federal awards, which conflicted with the Assistance Listing numbers used to report on the Federal awards, or on grant agreements. Additionally, subrecipients were included in the client’s Schedule of Expenditures of Federal awards which were later determined to be contractors. The schedule presented as part of the audit has been revised by management to address errors noted during the audit. Cause of Condition The Garden has not implemented proper internal control policies to adhere to the requirements of the Uniform Guidance. Effect of Condition Noncompliance may impact future funding from Federal awards. Recommendation We recommend the Garden implement proper internal control procedures to allow proper presentation of the Schedule of Expenditures of Federal Awards in accordance with Generally Accepted Accounting Principles.
Statistically Valid Sample: The sample was not intended to be, and was not, a statistically valid sample Repeat Finding: Yes (2022-002) Finding Type: Material Weakness, Material Noncompliance Criteria Reporting Per 2 CFR 200.502, the determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs. Generally, the activity pertains to events that require the non Federal statutes, regulations and the terms and conditions of Federal awards, such as: expenditures/expense transactions associated with awards including grants. Further, the Uniform Guidance compliance supplement notes, each recipient must report program outlays and program income on a cash or accrual basis, as prescribed by the Federal awarding agency. In accordance with the grant agreement and the reporting requirements for the State of New Jersey Department of Community Affairs, direct grants and pass through funds are fulfilled utilizing an advanced payment method and tracking reports. The grantee shall submit quarterly financial reports, in a format to be provided by the Department, and including the number of government full time employees responding to COVID 19 as supported by this funding. The reports are prepared and submitted to allow for relevant and reliable information to be provided to the Federal government or State of New Jersey for tracking purposes. The reports are the source documents for the grantee to prepare a schedule of expenditures of Federal awards (SEFA) for the period covered by the grantee’s financial statements in accordance with 2 CFR 200.502, Basis for determining Federal awards expended, for the SEFA. Procurement Non Federal entities other than states, including those operating Federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable Federal statutes and the procurement requirements identified in 2 CFR Part 200. A non Federal entity must: 1. Meet the general procurement standards in 2 CFR section 200.318, which include oversight of contractors’ performance, maintaining written standards of conduct for employees involved in contracting, awarding contracts only to responsible contractors, and maintaining records to document history of procurements. 2. Conduct all procurement transactions in a manner providing full and open competition, in accordance with 2 CFR section 200.319. 3. Use the micro purchase and small purchase methods only for procurements that meet the applicable criteria under 2 CFR sections 200.320(a) (1) and (2). Under the micro purchase method, the aggregate dollar amount does not exceed $10,000 ($2,000 in the case of acquisition for construction subject to the Wage Rate Requirements (Davis Bacon Act)). Small purchase procedures are used for purchases that exceed the micro purchase amount but do not exceed the simplified acquisition threshold ($250,000). Micro purchases may be awarded without soliciting competitive quotations if the non Federal entity considers the price to be reasonable (2 CFR section 200.320(a)). If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources (2 CFR section 200.320(b)). In accordance with the grant agreement and the reporting requirements for the State of New Jersey Department of Community Affairs, recipients may use award funds to enter into contracts to procure goods and services necessary to implement one or more of the eligible purposes outlined in sections 602(c) and 603(c) of the Act and Treasury’s Interim Final Rule and Final Rule. As such, recipients are expected to have procurement policies and procedures in place that comply with the procurement standards outlined in the Uniform Guidance. Under the program, St. Joseph’s Health, Inc. must follow the procurement standards in 2 CFR sections 200.318 through 200.327, including ensuring that the procurement method used for the contracts are appropriate based on the dollar amount and conditions specified in 2 CFR section 200.320. Internal Control Additionally, in accordance with Federal requirements, a non Federal entity shall maintain internal controls over Federal programs designed to provide reasonable assurance that transactions are executed in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award that could have a direct and material effect on a Federal program. Condition and Context Reporting On a quarterly basis, St. Joseph’s Health, Inc. (the System) prepares and reports to New Jersey Department of Community Affairs (the Department) the program expenditures for Federal funding amounts on the tracking report of expenditures, which are then used to prepare the annual SEFA in conjunction with the general ledger detail at the end of the fiscal year. While expenditures per the SEFA as prepared by the System were accurate and the quarterly reporting was accepted by the State, the System’s expenditures per the report of expenditures were based upon purchase order amounts, which include expenditures that were incurred subsequent to year end. Procurement Further, the System engaged multiple vendors for several projects under the G2022 09 grant that were above the $10K micro purchase threshold, but below the simplified acquisition threshold. However, the System did not obtain multiple quotes from different vendors to encourage fair competition in the market. The System’s policies and procedures to ensure compliance with the above compliance requirements did not include certain internal controls that were designed properly and operating effectively to ensure that the System properly reported costs on the report of expenditures or obtained the necessary quotes from potential bidders for procurements over the micro purchase threshold. Cause Management’s review of the submitted quarterly report of expenditures did not identify the need for a reconciliation of incurred expenditures and purchase order balances reported to the Department and as such, as there is a variance between the amounts reported on the SEFA and the amounts reported to the Department on the quarterly reports of approximately $458 thousand. We noted, however that this variance did not represent any unallowable costs. Additionally, Management did not retain or obtain the required documentation indicating quotes from multiple vendors were obtained for the ongoing construction projects under the grant. Effect The System had a material variance in the amount of expenditures reported to the Department as compared to the SEFA and did not obtain multiple quotations from vendors when making selections for various projects ongoing under the Federal program. Questioned Costs None Recommendation Reporting We recommend that the System strengthen its processes and internal controls to ensure the tracking of each report of expenditures provided to the Department has a reconciliation of the amount of expenditures incurred in the period based upon the general ledger and accounting records, used to prepare the annual SEFA, as compared to the purchase order balances. Procurement We recommend that the System strengthen its processes and internal controls to ensure that all procurement related transactions are supported by the appropriate bidding documentation as required by the Uniform Guidance for each respective bidding threshold. View of Responsible Official Management agrees with the auditor's recommendations and will strengthen its processes and internal controls to ensure the report of expenditures provided to the Department has a reconciliation of the amount of expenditures incurred in the period compared to the purchase order balances and all procurement transactions contain the required bidding documentation fro each bidding threshold in accordance with the Uniform Guidance.
Assistance Listing, Federal Agency, and Program Name - 93.493, Congressional Directives Federal Award Identification Number and Year - 2023 Pass through Entity - N/A Finding Type - Material weakness Repeat Finding - No Criteria - The Uniform Guidance requires organizations to properly reflect federal expenditures in the schedule of expenditures of federal awards (SEFA), as determined by 2 CFR 200.502. Condition - The total amount of expenditures originally reported on the SEFA excluded $1,024,472 of expenditures related to the Congressional Directives program. Questioned Costs - None Identification of How Questioned Costs Were Computed - N/A Context - All of the expenditures that were incurred related to the Congressional Directives program were originally excluded from the SEFA. The adjustment resulted in an additional major program. Although the SEFA was originally incorrect, the SEFA was corrected after this error was noted by the auditor. Cause and Effect - Internal control procedures over determining the correct amount of expenditures to record on the SEFA did not operate effectively. This resulted in an adjustment to the schedule of expenditures of federal awards. Recommendation - Internal control procedures should continue to be enforced to ensure the proper expenditures are reported in the schedule of federal awards. Views of Responsible Officials and Corrective Action Plan - Livingston County, Michigan will implement a review process going forward to ensure all expenses fall within the grant period.
Criteria: The Code of Federal Regulations (CFR) Section 200.510(b) states in part, “The auditee must also prepare a schedule of federal expenditures for the period covered by the auditee’s consolidated financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Condition: During our review of the December 31, 2023 Schedule of Expenditures of Federal Awards (SEFA) prepared by management, we noted that controls over the preparation of the SEFA were not properly designed resulting in adjustments to the SEFA for amounts passed through to subrecipients that were identified during the audit. Questioned Costs: N/A Cause and Effect: Internal controls over preparation of the SEFA are not operating effectively to ensure accuracy of the final SEFA. As a result of the condition noted above, certain adjustments were required to be made to the final SEFA. Recommendation: We recommend management review current internal controls over preparation and tracking of federal expenditures to ensure that all federal awards are captured and reported in the correct period and that internal controls are properly designed to detect and correct errors to the SEFA. Views of Responsible Officials and Planned Corrective Actions: Management agrees with this Single Audit Finding and response is included in the Corrective Action Plan.
Criteria: The Code of Federal Regulations (CFR) Section 200.510(b) states in part, “The auditee must also prepare a schedule of federal expenditures for the period covered by the auditee’s consolidated financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Condition: During our review of the December 31, 2023 Schedule of Expenditures of Federal Awards (SEFA) prepared by management, we noted that controls over the preparation of the SEFA were not properly designed resulting in adjustments to the SEFA for amounts passed through to subrecipients that were identified during the audit. Questioned Costs: N/A Cause and Effect: Internal controls over preparation of the SEFA are not operating effectively to ensure accuracy of the final SEFA. As a result of the condition noted above, certain adjustments were required to be made to the final SEFA. Recommendation: We recommend management review current internal controls over preparation and tracking of federal expenditures to ensure that all federal awards are captured and reported in the correct period and that internal controls are properly designed to detect and correct errors to the SEFA. Views of Responsible Officials and Planned Corrective Actions: Management agrees with this Single Audit Finding and response is included in the Corrective Action Plan.
Schedule of Expenditures of Federal Awards (SEFA) Federal Agency: U.S. Department of Health and Human Services; U.S. Department of Agriculture (USDA) Program: National Bioterrorism Hospital Preparedness Program (ALN 93.889); Immunization Cooperative Agreements (ALN 93. 268); COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)(ALN 93. 323); Child Support Services (ALN 93. 563); State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (ALN 10.561) Pass-through Entity: Minnesota Department of Health; Minnesota Department of Human Services Federal Assistance Identification Number or Pass-Through Number: U90TP000529; 6NH23P0007370502; NH23P922628; NH23IP922628; NU50CK000508; 2001MNCEST; 2101MNCSES; 212MN127Q7503; 212MN101S2520; 212MN101S2514 Federal Award Year: Year ended December 31, 2023 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matter Compliance Finding Criteria: 2 CFR 200.303(a) requires that each 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." 2 CFR 200.510(b) requires that “The auditee must prepare a schedule of expenditures of Federal awards awards (the “schedule”) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with ss 200.502... ...At minimum, the schedule must... ...(3) Provide total Federal awards expended for each individual Federal program and the Assistance Listings Number or other identifying number when the Assistance Listings information is not available…” Condition: While testing the SEFA, we noted that internal controls were not operating effectively over the preparation of the SEFA. In addition, we noted the following errors in the original SEFA we received for the audit: - $1,284,631 of expenditures were improperly included in ALN 93.889 when the amount should have been included in ALN 93.268. - $30,394 of expenditures was improperly included in ALN 93.889 when the amount should have been included in ALN 93.323. - $626,894 of expenditures related to ALN 93.563 was missing from the schedule. - $61,290 of expenditures related to ALN 10.561 was missing from the schedule. Cause: The errors of $1,284,631 and $30,394 related to ALN 93.889 were caused by the county hospital’s system of assigning identifying numbers within the chart of accounts not being applied to awards managed outside of the Hennepin Health Foundation. The errors of $626,894 related to ALN 93.563 and $61,290 related to ALN 10.561 related to the County’s reducing expenditures by a reversal of a prior year receivable transaction when determining the amount of expenditures. Effect: The errors in the preparation of the SEFA indicate noncompliance with the requirements for the Schedule, including ensuring that it is complete and accurate. Context: Approximately $2 million of errors were noted over the SEFA with total expenditures of approximately $360 million. Questioned Costs: None Repeat Finding?: No Recommendation: We recommend that the County strengthen its processes and controls over the preparation of the SEFA. Views of Responsible Officials: Hennepin County has reviewed and agrees with the finding and the recommendation.
Schedule of Expenditures of Federal Awards (SEFA) Federal Agency: U.S. Department of Health and Human Services; U.S. Department of Agriculture (USDA) Program: National Bioterrorism Hospital Preparedness Program (ALN 93.889); Immunization Cooperative Agreements (ALN 93. 268); COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)(ALN 93. 323); Child Support Services (ALN 93. 563); State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (ALN 10.561) Pass-through Entity: Minnesota Department of Health; Minnesota Department of Human Services Federal Assistance Identification Number or Pass-Through Number: U90TP000529; 6NH23P0007370502; NH23P922628; NH23IP922628; NU50CK000508; 2001MNCEST; 2101MNCSES; 212MN127Q7503; 212MN101S2520; 212MN101S2514 Federal Award Year: Year ended December 31, 2023 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matter Compliance Finding Criteria: 2 CFR 200.303(a) requires that each 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." 2 CFR 200.510(b) requires that “The auditee must prepare a schedule of expenditures of Federal awards awards (the “schedule”) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with ss 200.502... ...At minimum, the schedule must... ...(3) Provide total Federal awards expended for each individual Federal program and the Assistance Listings Number or other identifying number when the Assistance Listings information is not available…” Condition: While testing the SEFA, we noted that internal controls were not operating effectively over the preparation of the SEFA. In addition, we noted the following errors in the original SEFA we received for the audit: - $1,284,631 of expenditures were improperly included in ALN 93.889 when the amount should have been included in ALN 93.268. - $30,394 of expenditures was improperly included in ALN 93.889 when the amount should have been included in ALN 93.323. - $626,894 of expenditures related to ALN 93.563 was missing from the schedule. - $61,290 of expenditures related to ALN 10.561 was missing from the schedule. Cause: The errors of $1,284,631 and $30,394 related to ALN 93.889 were caused by the county hospital’s system of assigning identifying numbers within the chart of accounts not being applied to awards managed outside of the Hennepin Health Foundation. The errors of $626,894 related to ALN 93.563 and $61,290 related to ALN 10.561 related to the County’s reducing expenditures by a reversal of a prior year receivable transaction when determining the amount of expenditures. Effect: The errors in the preparation of the SEFA indicate noncompliance with the requirements for the Schedule, including ensuring that it is complete and accurate. Context: Approximately $2 million of errors were noted over the SEFA with total expenditures of approximately $360 million. Questioned Costs: None Repeat Finding?: No Recommendation: We recommend that the County strengthen its processes and controls over the preparation of the SEFA. Views of Responsible Officials: Hennepin County has reviewed and agrees with the finding and the recommendation.
Schedule of Expenditures of Federal Awards (SEFA) Federal Agency: U.S. Department of Health and Human Services; U.S. Department of Agriculture (USDA) Program: National Bioterrorism Hospital Preparedness Program (ALN 93.889); Immunization Cooperative Agreements (ALN 93. 268); COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)(ALN 93. 323); Child Support Services (ALN 93. 563); State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (ALN 10.561) Pass-through Entity: Minnesota Department of Health; Minnesota Department of Human Services Federal Assistance Identification Number or Pass-Through Number: U90TP000529; 6NH23P0007370502; NH23P922628; NH23IP922628; NU50CK000508; 2001MNCEST; 2101MNCSES; 212MN127Q7503; 212MN101S2520; 212MN101S2514 Federal Award Year: Year ended December 31, 2023 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matter Compliance Finding Criteria: 2 CFR 200.303(a) requires that each 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." 2 CFR 200.510(b) requires that “The auditee must prepare a schedule of expenditures of Federal awards awards (the “schedule”) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with ss 200.502... ...At minimum, the schedule must... ...(3) Provide total Federal awards expended for each individual Federal program and the Assistance Listings Number or other identifying number when the Assistance Listings information is not available…” Condition: While testing the SEFA, we noted that internal controls were not operating effectively over the preparation of the SEFA. In addition, we noted the following errors in the original SEFA we received for the audit: - $1,284,631 of expenditures were improperly included in ALN 93.889 when the amount should have been included in ALN 93.268. - $30,394 of expenditures was improperly included in ALN 93.889 when the amount should have been included in ALN 93.323. - $626,894 of expenditures related to ALN 93.563 was missing from the schedule. - $61,290 of expenditures related to ALN 10.561 was missing from the schedule. Cause: The errors of $1,284,631 and $30,394 related to ALN 93.889 were caused by the county hospital’s system of assigning identifying numbers within the chart of accounts not being applied to awards managed outside of the Hennepin Health Foundation. The errors of $626,894 related to ALN 93.563 and $61,290 related to ALN 10.561 related to the County’s reducing expenditures by a reversal of a prior year receivable transaction when determining the amount of expenditures. Effect: The errors in the preparation of the SEFA indicate noncompliance with the requirements for the Schedule, including ensuring that it is complete and accurate. Context: Approximately $2 million of errors were noted over the SEFA with total expenditures of approximately $360 million. Questioned Costs: None Repeat Finding?: No Recommendation: We recommend that the County strengthen its processes and controls over the preparation of the SEFA. Views of Responsible Officials: Hennepin County has reviewed and agrees with the finding and the recommendation.
Schedule of Expenditures of Federal Awards (SEFA) Federal Agency: U.S. Department of Health and Human Services; U.S. Department of Agriculture (USDA) Program: National Bioterrorism Hospital Preparedness Program (ALN 93.889); Immunization Cooperative Agreements (ALN 93. 268); COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)(ALN 93. 323); Child Support Services (ALN 93. 563); State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (ALN 10.561) Pass-through Entity: Minnesota Department of Health; Minnesota Department of Human Services Federal Assistance Identification Number or Pass-Through Number: U90TP000529; 6NH23P0007370502; NH23P922628; NH23IP922628; NU50CK000508; 2001MNCEST; 2101MNCSES; 212MN127Q7503; 212MN101S2520; 212MN101S2514 Federal Award Year: Year ended December 31, 2023 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matter Compliance Finding Criteria: 2 CFR 200.303(a) requires that each 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." 2 CFR 200.510(b) requires that “The auditee must prepare a schedule of expenditures of Federal awards awards (the “schedule”) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with ss 200.502... ...At minimum, the schedule must... ...(3) Provide total Federal awards expended for each individual Federal program and the Assistance Listings Number or other identifying number when the Assistance Listings information is not available…” Condition: While testing the SEFA, we noted that internal controls were not operating effectively over the preparation of the SEFA. In addition, we noted the following errors in the original SEFA we received for the audit: - $1,284,631 of expenditures were improperly included in ALN 93.889 when the amount should have been included in ALN 93.268. - $30,394 of expenditures was improperly included in ALN 93.889 when the amount should have been included in ALN 93.323. - $626,894 of expenditures related to ALN 93.563 was missing from the schedule. - $61,290 of expenditures related to ALN 10.561 was missing from the schedule. Cause: The errors of $1,284,631 and $30,394 related to ALN 93.889 were caused by the county hospital’s system of assigning identifying numbers within the chart of accounts not being applied to awards managed outside of the Hennepin Health Foundation. The errors of $626,894 related to ALN 93.563 and $61,290 related to ALN 10.561 related to the County’s reducing expenditures by a reversal of a prior year receivable transaction when determining the amount of expenditures. Effect: The errors in the preparation of the SEFA indicate noncompliance with the requirements for the Schedule, including ensuring that it is complete and accurate. Context: Approximately $2 million of errors were noted over the SEFA with total expenditures of approximately $360 million. Questioned Costs: None Repeat Finding?: No Recommendation: We recommend that the County strengthen its processes and controls over the preparation of the SEFA. Views of Responsible Officials: Hennepin County has reviewed and agrees with the finding and the recommendation.
Schedule of Expenditures of Federal Awards (SEFA) Federal Agency: U.S. Department of Health and Human Services; U.S. Department of Agriculture (USDA) Program: National Bioterrorism Hospital Preparedness Program (ALN 93.889); Immunization Cooperative Agreements (ALN 93. 268); COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)(ALN 93. 323); Child Support Services (ALN 93. 563); State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (ALN 10.561) Pass-through Entity: Minnesota Department of Health; Minnesota Department of Human Services Federal Assistance Identification Number or Pass-Through Number: U90TP000529; 6NH23P0007370502; NH23P922628; NH23IP922628; NU50CK000508; 2001MNCEST; 2101MNCSES; 212MN127Q7503; 212MN101S2520; 212MN101S2514 Federal Award Year: Year ended December 31, 2023 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matter Compliance Finding Criteria: 2 CFR 200.303(a) requires that each 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." 2 CFR 200.510(b) requires that “The auditee must prepare a schedule of expenditures of Federal awards awards (the “schedule”) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with ss 200.502... ...At minimum, the schedule must... ...(3) Provide total Federal awards expended for each individual Federal program and the Assistance Listings Number or other identifying number when the Assistance Listings information is not available…” Condition: While testing the SEFA, we noted that internal controls were not operating effectively over the preparation of the SEFA. In addition, we noted the following errors in the original SEFA we received for the audit: - $1,284,631 of expenditures were improperly included in ALN 93.889 when the amount should have been included in ALN 93.268. - $30,394 of expenditures was improperly included in ALN 93.889 when the amount should have been included in ALN 93.323. - $626,894 of expenditures related to ALN 93.563 was missing from the schedule. - $61,290 of expenditures related to ALN 10.561 was missing from the schedule. Cause: The errors of $1,284,631 and $30,394 related to ALN 93.889 were caused by the county hospital’s system of assigning identifying numbers within the chart of accounts not being applied to awards managed outside of the Hennepin Health Foundation. The errors of $626,894 related to ALN 93.563 and $61,290 related to ALN 10.561 related to the County’s reducing expenditures by a reversal of a prior year receivable transaction when determining the amount of expenditures. Effect: The errors in the preparation of the SEFA indicate noncompliance with the requirements for the Schedule, including ensuring that it is complete and accurate. Context: Approximately $2 million of errors were noted over the SEFA with total expenditures of approximately $360 million. Questioned Costs: None Repeat Finding?: No Recommendation: We recommend that the County strengthen its processes and controls over the preparation of the SEFA. Views of Responsible Officials: Hennepin County has reviewed and agrees with the finding and the recommendation.
FINDING 2023-001 Program Information: Substance Abuse and Mental Health Services Projects (ALN #93.243) COVID-19 Education Stabilization Fund (ALN #84.425C) Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): L. Reporting - The auditee must prepare a schedule of expenditures of Federal awards (the “SEFA”) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502 Basis for determining Federal awards expended. At a minimum, the schedule must: (1) List individual Federal programs by Federal agency. For a cluster of programs, provide the cluster name, list individual Federal programs within the cluster of programs, and provide the applicable Federal agency name. For Research and Development (“R&D”), total Federal awards expended must be shown either by individual Federal award or by Federal agency and major subdivision within the Federal agency. (2) For Federal awards received as a subrecipient, the name of the passthrough entity and identifying number assigned by the pass-through entity must be included. (3) Provide total Federal awards expended for each individual Federal program and the Assistance Listing number or other identifying number when the Assistance Listing information is not available. For a cluster of programs also provide the total for the cluster. (4) Include the total amount provided to subrecipients from each Federal program. (5) For loan or loan guarantee programs described in 2 CFR 200.502(b), identify in the notes to the schedule the balances outstanding at the end of the audit period. This is in addition to including the total Federal awards expended for loan or loan guarantee programs in the schedule. (6) Include notes that describe that significant accounting policies used in preparing the schedule and note whether or not the auditee elected to use the 10% de minimis cost rate as covered in 2 CFR 200.414. FINDING 2023-001 Program Information: Substance Abuse and Mental Health Services Projects (ALN #93.243) COVID-19 Education Stabilization Fund (ALN #84.425C) Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): L. Reporting - The auditee must prepare a schedule of expenditures of Federal awards (the “SEFA”) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502 Basis for determining Federal awards expended. At a minimum, the schedule must: (1) List individual Federal programs by Federal agency. For a cluster of programs, provide the cluster name, list individual Federal programs within the cluster of programs, and provide the applicable Federal agency name. For Research and Development (“R&D”), total Federal awards expended must be shown either by individual Federal award or by Federal agency and major subdivision within the Federal agency. (2) For Federal awards received as a subrecipient, the name of the passthrough entity and identifying number assigned by the pass-through entity must be included. (3) Provide total Federal awards expended for each individual Federal program and the Assistance Listing number or other identifying number when the Assistance Listing information is not available. For a cluster of programs also provide the total for the cluster. (4) Include the total amount provided to subrecipients from each Federal program. (5) For loan or loan guarantee programs described in 2 CFR 200.502(b), identify in the notes to the schedule the balances outstanding at the end of the audit period. This is in addition to including the total Federal awards expended for loan or loan guarantee programs in the schedule. (6) Include notes that describe that significant accounting policies used in preparing the schedule and note whether or not the auditee elected to use the 10% de minimis cost rate as covered in 2 CFR 200.414. Condition: The SEFA, as prepared by management erroneously included expenditures previously incurred and reported in fiscal year 2022, resulting in an overstatement of $7,875 for the Substance Abuse and Mental Health Service Project. Additionally, COVID-19 Education Stabilization Fund expenditures were not complete, resulting in an understatement of $6,000 for the COVID-19 Education Stabilization Fund. Cause: Administrative oversight with respect to preparation of the SEFA. Effect or Potential Effect: The original draft SEFA was overstated. Questioned Costs: None Context: Due to an error in disbursing grant funds to an incorrect local club in fiscal year 2022, the Alliance attempted to correct this mistake by disbursing additional funds to the correct club in fiscal year 2023. The Alliance included the remedied disbursement on the 2023 SEFA, which resulted in a $7,875 overstatement of expenditures that had already been incurred and reported on the 2022 SEFA. The omission of costs allocated to the COVID-19 Education Stabilization Fund resulted in expenditures being understated by $6,000. Identification as a Repeat Finding: No similar findings noted in the prior year. Recommendation: We recommend that the Alliance enhance its procedures and internal controls with respect to preparation and review of the SEFA. Views of Responsible Officials and Planned Corrective Actions: Management will enhance procedures and internal controls with respect to the preparation and review of the SEFA, by reviewing the detail of expenses included in the prior year SEFA with current year expenses, to prevent duplicate entries being reported.
FINDING 2023-001 Program Information: Substance Abuse and Mental Health Services Projects (ALN #93.243) COVID-19 Education Stabilization Fund (ALN #84.425C) Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): L. Reporting - The auditee must prepare a schedule of expenditures of Federal awards (the “SEFA”) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502 Basis for determining Federal awards expended. At a minimum, the schedule must: (1) List individual Federal programs by Federal agency. For a cluster of programs, provide the cluster name, list individual Federal programs within the cluster of programs, and provide the applicable Federal agency name. For Research and Development (“R&D”), total Federal awards expended must be shown either by individual Federal award or by Federal agency and major subdivision within the Federal agency. (2) For Federal awards received as a subrecipient, the name of the passthrough entity and identifying number assigned by the pass-through entity must be included. (3) Provide total Federal awards expended for each individual Federal program and the Assistance Listing number or other identifying number when the Assistance Listing information is not available. For a cluster of programs also provide the total for the cluster. (4) Include the total amount provided to subrecipients from each Federal program. (5) For loan or loan guarantee programs described in 2 CFR 200.502(b), identify in the notes to the schedule the balances outstanding at the end of the audit period. This is in addition to including the total Federal awards expended for loan or loan guarantee programs in the schedule. (6) Include notes that describe that significant accounting policies used in preparing the schedule and note whether or not the auditee elected to use the 10% de minimis cost rate as covered in 2 CFR 200.414. FINDING 2023-001 Program Information: Substance Abuse and Mental Health Services Projects (ALN #93.243) COVID-19 Education Stabilization Fund (ALN #84.425C) Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): L. Reporting - The auditee must prepare a schedule of expenditures of Federal awards (the “SEFA”) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502 Basis for determining Federal awards expended. At a minimum, the schedule must: (1) List individual Federal programs by Federal agency. For a cluster of programs, provide the cluster name, list individual Federal programs within the cluster of programs, and provide the applicable Federal agency name. For Research and Development (“R&D”), total Federal awards expended must be shown either by individual Federal award or by Federal agency and major subdivision within the Federal agency. (2) For Federal awards received as a subrecipient, the name of the passthrough entity and identifying number assigned by the pass-through entity must be included. (3) Provide total Federal awards expended for each individual Federal program and the Assistance Listing number or other identifying number when the Assistance Listing information is not available. For a cluster of programs also provide the total for the cluster. (4) Include the total amount provided to subrecipients from each Federal program. (5) For loan or loan guarantee programs described in 2 CFR 200.502(b), identify in the notes to the schedule the balances outstanding at the end of the audit period. This is in addition to including the total Federal awards expended for loan or loan guarantee programs in the schedule. (6) Include notes that describe that significant accounting policies used in preparing the schedule and note whether or not the auditee elected to use the 10% de minimis cost rate as covered in 2 CFR 200.414. Condition: The SEFA, as prepared by management erroneously included expenditures previously incurred and reported in fiscal year 2022, resulting in an overstatement of $7,875 for the Substance Abuse and Mental Health Service Project. Additionally, COVID-19 Education Stabilization Fund expenditures were not complete, resulting in an understatement of $6,000 for the COVID-19 Education Stabilization Fund. Cause: Administrative oversight with respect to preparation of the SEFA. Effect or Potential Effect: The original draft SEFA was overstated. Questioned Costs: None Context: Due to an error in disbursing grant funds to an incorrect local club in fiscal year 2022, the Alliance attempted to correct this mistake by disbursing additional funds to the correct club in fiscal year 2023. The Alliance included the remedied disbursement on the 2023 SEFA, which resulted in a $7,875 overstatement of expenditures that had already been incurred and reported on the 2022 SEFA. The omission of costs allocated to the COVID-19 Education Stabilization Fund resulted in expenditures being understated by $6,000. Identification as a Repeat Finding: No similar findings noted in the prior year. Recommendation: We recommend that the Alliance enhance its procedures and internal controls with respect to preparation and review of the SEFA. Views of Responsible Officials and Planned Corrective Actions: Management will enhance procedures and internal controls with respect to the preparation and review of the SEFA, by reviewing the detail of expenses included in the prior year SEFA with current year expenses, to prevent duplicate entries being reported.
2023-001 – Preparation of the Schedule of Expenditures of Federal Awards Identification of the Federal Program – 93.224/93.527 Health Center Program Cluster Criteria – CFR Section §200.510(b) states in part: “The auditee must also prepare a schedule of expenditures of Federal awards (Schedule) for the period covered by the auditee's financial statements which must include the total Federal awards expended as determined in accordance with §200.502”. CFR Section §200.502(a) also states that, “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs”. Condition – We noted that there were significant adjustments needed to present a complete and accurate Schedule. Cause – WWH’s internal controls over preparation and review of the Schedule were not properly implemented for the year ended December 31, 2023. Such internal controls were designed to require timely review of the accuracy of the Schedule by appropriate personnel. Effect – The Schedule for the year ended December 31, 2023 inappropriately included $250,500 of expenditures related to previous years. Questioned costs – none Context – Internal controls or processes in place were not implemented as intended to ensure an accurate Schedule was prepared. Repeat finding – No Recommendation – We recommend the Schedule to be reviewed timely and with sufficient precision by the appropriate level of personnel. View of Responsible Officials - Management agrees with the Federal Award Finding regarding the determination of when a Federal award is expended. As part of the Corrective Action Plan, Grants management staff from Finance and Program departments are meeting regularly to ensure that the expenditures are recorded in the appropriate year.
2023-001 – Preparation of the Schedule of Expenditures of Federal Awards Identification of the Federal Program – 93.224/93.527 Health Center Program Cluster Criteria – CFR Section §200.510(b) states in part: “The auditee must also prepare a schedule of expenditures of Federal awards (Schedule) for the period covered by the auditee's financial statements which must include the total Federal awards expended as determined in accordance with §200.502”. CFR Section §200.502(a) also states that, “The determination of when a Federal award is expended must be based on when the activity related to the Federal award occurs”. Condition – We noted that there were significant adjustments needed to present a complete and accurate Schedule. Cause – WWH’s internal controls over preparation and review of the Schedule were not properly implemented for the year ended December 31, 2023. Such internal controls were designed to require timely review of the accuracy of the Schedule by appropriate personnel. Effect – The Schedule for the year ended December 31, 2023 inappropriately included $250,500 of expenditures related to previous years. Questioned costs – none Context – Internal controls or processes in place were not implemented as intended to ensure an accurate Schedule was prepared. Repeat finding – No Recommendation – We recommend the Schedule to be reviewed timely and with sufficient precision by the appropriate level of personnel. View of Responsible Officials - Management agrees with the Federal Award Finding regarding the determination of when a Federal award is expended. As part of the Corrective Action Plan, Grants management staff from Finance and Program departments are meeting regularly to ensure that the expenditures are recorded in the appropriate year.
Finding 2023-001 – Reporting Information of the federal program: Federal Grantor: Department of Defense (DOD) Assistance Listing No.: 12.420, Military Medical Research and Development Pass-Through Grantor: Johns Hopkins University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.172, Human Genome Research Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.226, Research on Healthcare Costs, Quality and Outcomes Pass-Through Grantor: The Regents of the University of Michigan Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.242, Mental Health Research Grants Pass-Through Grantor: Rutgers State University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.307, Minority Health and Health Disparities Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.310, Trans-NIH Research Support Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.350, National Center for Advancing Translational Sciences Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.351, Research Infrastructure Program Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.361, Nursing Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.368, 21st Century Cures Act – Precision Medicine Initiative Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.394, Cancer Detection and Diagnosis Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.395, Cancer Treatment Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.396, Cancer Biology Research Pass-Through Grantor: Tulane University, Louisiana State University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.397, Cancer Centers Support Grants Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.667, Social Services Block Grant Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.837, Cardiovascular Diseases Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.838, Lung Diseases Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.847, Diabetes, Digestive, and Kidney Diseases Extramural Research Pass-Through Grantors: Northwestern University, Duke University, University of Washington, The Regents of University of Michigan Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.853, Extramural Research Programs in the Neurosciences and Neurological Disorders Pass-Through Grantor: Rush University Medical Center Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.855, Allergy, Immunology and Transplantation Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.859, Biomedical Research and Research Training Pass-Through Grantor: University of Wisconsin – Madison Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.865, Child Health and Human Development Extramural Research Pass-Through Grantors: Northwestern University, University of Washington, The Regents of the University of California Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.866, Aging Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.946, Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.994, Maternal and Child Health Services Block Grant to the States Pass-Through Grantor: Northwestern Memorial Hospital Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” The Uniform Guidance 2 CFR section 200.510 states, “(b) Schedule of expenditures of Federal awards. The auditee must also prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with §200.502 Basis for determining Federal awards expended.” Condition: Certain grants related to the Research and Development Cluster were misstated by $233,405 on the preliminary schedule of expenditures of federal awards (the Schedule) provided by management due to the inappropriate classification of costs within the general ledger; the final Schedule was corrected. In addition, an award which was not a federal grant award with expenditures of $148,388 was included on the preliminary Schedule provided by management. The final Schedule was corrected. Cause: Endeavor’s internal controls over the preparation of the Schedule were not sufficient to properly accumulate and accurately report all expenditures of federal awards. Effect or Potential Effect: Inaccurate or improper reporting of expenditures results in a misstated Schedule and can also potentially result in insufficient testing of the major programs or improper identification of major programs for audit purposes. Questioned costs: None. Context: The table below reflects the preliminary and adjusted assistance listing balances on the Schedule (only assistance listing programs which changed are included below): Assistance Listing No. Name of Federal Program Preliminary Schedule Adjusted Schedule Change 12.420 Military Medical Research and Development $ 241,025 $ 224,418 $ 16,607 93.172 Human Genome Research 14,874 15,121 (247) 93.226 Research on Healthcare Costs, Quality and Outcomes 251,325 248,842 2,483 93.242 Mental Health Research Grants 1,616,503 1,617,376 (873) 93.307 Minority Health and Health Disparities Research 17,323 15,122 2,201 93.310 Trans-NIH Research Support 313,459 313,490 (31) 93.350 National Center for Advancing Translational Sciences 516,734 518,429 (1,695) 93.351 Research Infrastructure Program 242,436 232,058 10,378 93.361 Nursing Research 8,745 7,645 1,100 93.368 21st Century Cures Act – Precision Medicine Initiative 100,324 94,609 5,715 93.394 Cancer Detection and Diagnosis Research 847,959 816,528 31,431 93.395 Cancer Treatment Research 438,349 439,286 (937) 93.396 Cancer Biology Research 93,919 88,642 5,277 93.397 Cancer Centers Support Grants 15,552 14,078 1,474 93.667 Social Services Block Grant 19,619 27,170 (7,551) 93.837 Cardiovascular Diseases Research 193,160 188,850 4,310 93.838 Lung Diseases Research 482,934 471,427 11,507 93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research 1,075,493 1,035,041 40,452 93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders 1,645,025 1,596,611 48,414 93.855 Allergy, Immunology and Transplantation Research 73,869 72,630 1,239 93.859 Biomedical Research and Research Training 363,336 366,791 (3,455) 93.865 Child Health and Human Development Extramural Research 3,790,797 3,733,008 57,789 93.866 Aging Research 1,101,363 1,098,891 2,472 93.946 Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs 80,039 78,033 2,006 93.994 Maternal and Child Health Services Block Grant to the States 171,995 168,656 3,339 The Role of Oral Care in Nonventilator Hospital-Acquired Pneumonia (NVHAP) Prevention 148,388 – 148,388 Total $ 13,864,545 $ 13,482,752 $ 381,793 Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should implement internal controls to ensure amounts are appropriately accumulated and reported on the Schedule and all federal expenditures are appropriately identified and reported on the Schedule. Views of responsible officials: Award amounts were changed on the Schedule after management’s review was executed. Management acknowledges that implementing the new Enterprise Resource Planning (ERP) system, in 2023 presented changes to the SEFA reporting. Management has identified and addressed the reporting issues within the new system to ensure that the grant totals are appropriately captured in the SEFA. Endeavor will enhance grant management award processes by revising its procedures and adding additional controls to monitor for accuracy of the core data. Management will reinforce the importance of timeliness and accuracy of the Schedule reporting totals to facilitate accurate reporting.
Finding 2023-001 – Reporting Information of the federal program: Federal Grantor: Department of Defense (DOD) Assistance Listing No.: 12.420, Military Medical Research and Development Pass-Through Grantor: Johns Hopkins University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.172, Human Genome Research Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.226, Research on Healthcare Costs, Quality and Outcomes Pass-Through Grantor: The Regents of the University of Michigan Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.242, Mental Health Research Grants Pass-Through Grantor: Rutgers State University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.307, Minority Health and Health Disparities Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.310, Trans-NIH Research Support Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.350, National Center for Advancing Translational Sciences Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.351, Research Infrastructure Program Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.361, Nursing Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.368, 21st Century Cures Act – Precision Medicine Initiative Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.394, Cancer Detection and Diagnosis Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.395, Cancer Treatment Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.396, Cancer Biology Research Pass-Through Grantor: Tulane University, Louisiana State University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.397, Cancer Centers Support Grants Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.667, Social Services Block Grant Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.837, Cardiovascular Diseases Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.838, Lung Diseases Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.847, Diabetes, Digestive, and Kidney Diseases Extramural Research Pass-Through Grantors: Northwestern University, Duke University, University of Washington, The Regents of University of Michigan Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.853, Extramural Research Programs in the Neurosciences and Neurological Disorders Pass-Through Grantor: Rush University Medical Center Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.855, Allergy, Immunology and Transplantation Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.859, Biomedical Research and Research Training Pass-Through Grantor: University of Wisconsin – Madison Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.865, Child Health and Human Development Extramural Research Pass-Through Grantors: Northwestern University, University of Washington, The Regents of the University of California Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.866, Aging Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.946, Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.994, Maternal and Child Health Services Block Grant to the States Pass-Through Grantor: Northwestern Memorial Hospital Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” The Uniform Guidance 2 CFR section 200.510 states, “(b) Schedule of expenditures of Federal awards. The auditee must also prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with §200.502 Basis for determining Federal awards expended.” Condition: Certain grants related to the Research and Development Cluster were misstated by $233,405 on the preliminary schedule of expenditures of federal awards (the Schedule) provided by management due to the inappropriate classification of costs within the general ledger; the final Schedule was corrected. In addition, an award which was not a federal grant award with expenditures of $148,388 was included on the preliminary Schedule provided by management. The final Schedule was corrected. Cause: Endeavor’s internal controls over the preparation of the Schedule were not sufficient to properly accumulate and accurately report all expenditures of federal awards. Effect or Potential Effect: Inaccurate or improper reporting of expenditures results in a misstated Schedule and can also potentially result in insufficient testing of the major programs or improper identification of major programs for audit purposes. Questioned costs: None. Context: The table below reflects the preliminary and adjusted assistance listing balances on the Schedule (only assistance listing programs which changed are included below): Assistance Listing No. Name of Federal Program Preliminary Schedule Adjusted Schedule Change 12.420 Military Medical Research and Development $ 241,025 $ 224,418 $ 16,607 93.172 Human Genome Research 14,874 15,121 (247) 93.226 Research on Healthcare Costs, Quality and Outcomes 251,325 248,842 2,483 93.242 Mental Health Research Grants 1,616,503 1,617,376 (873) 93.307 Minority Health and Health Disparities Research 17,323 15,122 2,201 93.310 Trans-NIH Research Support 313,459 313,490 (31) 93.350 National Center for Advancing Translational Sciences 516,734 518,429 (1,695) 93.351 Research Infrastructure Program 242,436 232,058 10,378 93.361 Nursing Research 8,745 7,645 1,100 93.368 21st Century Cures Act – Precision Medicine Initiative 100,324 94,609 5,715 93.394 Cancer Detection and Diagnosis Research 847,959 816,528 31,431 93.395 Cancer Treatment Research 438,349 439,286 (937) 93.396 Cancer Biology Research 93,919 88,642 5,277 93.397 Cancer Centers Support Grants 15,552 14,078 1,474 93.667 Social Services Block Grant 19,619 27,170 (7,551) 93.837 Cardiovascular Diseases Research 193,160 188,850 4,310 93.838 Lung Diseases Research 482,934 471,427 11,507 93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research 1,075,493 1,035,041 40,452 93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders 1,645,025 1,596,611 48,414 93.855 Allergy, Immunology and Transplantation Research 73,869 72,630 1,239 93.859 Biomedical Research and Research Training 363,336 366,791 (3,455) 93.865 Child Health and Human Development Extramural Research 3,790,797 3,733,008 57,789 93.866 Aging Research 1,101,363 1,098,891 2,472 93.946 Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs 80,039 78,033 2,006 93.994 Maternal and Child Health Services Block Grant to the States 171,995 168,656 3,339 The Role of Oral Care in Nonventilator Hospital-Acquired Pneumonia (NVHAP) Prevention 148,388 – 148,388 Total $ 13,864,545 $ 13,482,752 $ 381,793 Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should implement internal controls to ensure amounts are appropriately accumulated and reported on the Schedule and all federal expenditures are appropriately identified and reported on the Schedule. Views of responsible officials: Award amounts were changed on the Schedule after management’s review was executed. Management acknowledges that implementing the new Enterprise Resource Planning (ERP) system, in 2023 presented changes to the SEFA reporting. Management has identified and addressed the reporting issues within the new system to ensure that the grant totals are appropriately captured in the SEFA. Endeavor will enhance grant management award processes by revising its procedures and adding additional controls to monitor for accuracy of the core data. Management will reinforce the importance of timeliness and accuracy of the Schedule reporting totals to facilitate accurate reporting.
Finding 2023-001 – Reporting Information of the federal program: Federal Grantor: Department of Defense (DOD) Assistance Listing No.: 12.420, Military Medical Research and Development Pass-Through Grantor: Johns Hopkins University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.172, Human Genome Research Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.226, Research on Healthcare Costs, Quality and Outcomes Pass-Through Grantor: The Regents of the University of Michigan Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.242, Mental Health Research Grants Pass-Through Grantor: Rutgers State University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.307, Minority Health and Health Disparities Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.310, Trans-NIH Research Support Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.350, National Center for Advancing Translational Sciences Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.351, Research Infrastructure Program Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.361, Nursing Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.368, 21st Century Cures Act – Precision Medicine Initiative Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.394, Cancer Detection and Diagnosis Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.395, Cancer Treatment Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.396, Cancer Biology Research Pass-Through Grantor: Tulane University, Louisiana State University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.397, Cancer Centers Support Grants Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.667, Social Services Block Grant Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.837, Cardiovascular Diseases Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.838, Lung Diseases Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.847, Diabetes, Digestive, and Kidney Diseases Extramural Research Pass-Through Grantors: Northwestern University, Duke University, University of Washington, The Regents of University of Michigan Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.853, Extramural Research Programs in the Neurosciences and Neurological Disorders Pass-Through Grantor: Rush University Medical Center Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.855, Allergy, Immunology and Transplantation Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.859, Biomedical Research and Research Training Pass-Through Grantor: University of Wisconsin – Madison Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.865, Child Health and Human Development Extramural Research Pass-Through Grantors: Northwestern University, University of Washington, The Regents of the University of California Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.866, Aging Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.946, Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.994, Maternal and Child Health Services Block Grant to the States Pass-Through Grantor: Northwestern Memorial Hospital Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” The Uniform Guidance 2 CFR section 200.510 states, “(b) Schedule of expenditures of Federal awards. The auditee must also prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with §200.502 Basis for determining Federal awards expended.” Condition: Certain grants related to the Research and Development Cluster were misstated by $233,405 on the preliminary schedule of expenditures of federal awards (the Schedule) provided by management due to the inappropriate classification of costs within the general ledger; the final Schedule was corrected. In addition, an award which was not a federal grant award with expenditures of $148,388 was included on the preliminary Schedule provided by management. The final Schedule was corrected. Cause: Endeavor’s internal controls over the preparation of the Schedule were not sufficient to properly accumulate and accurately report all expenditures of federal awards. Effect or Potential Effect: Inaccurate or improper reporting of expenditures results in a misstated Schedule and can also potentially result in insufficient testing of the major programs or improper identification of major programs for audit purposes. Questioned costs: None. Context: The table below reflects the preliminary and adjusted assistance listing balances on the Schedule (only assistance listing programs which changed are included below): Assistance Listing No. Name of Federal Program Preliminary Schedule Adjusted Schedule Change 12.420 Military Medical Research and Development $ 241,025 $ 224,418 $ 16,607 93.172 Human Genome Research 14,874 15,121 (247) 93.226 Research on Healthcare Costs, Quality and Outcomes 251,325 248,842 2,483 93.242 Mental Health Research Grants 1,616,503 1,617,376 (873) 93.307 Minority Health and Health Disparities Research 17,323 15,122 2,201 93.310 Trans-NIH Research Support 313,459 313,490 (31) 93.350 National Center for Advancing Translational Sciences 516,734 518,429 (1,695) 93.351 Research Infrastructure Program 242,436 232,058 10,378 93.361 Nursing Research 8,745 7,645 1,100 93.368 21st Century Cures Act – Precision Medicine Initiative 100,324 94,609 5,715 93.394 Cancer Detection and Diagnosis Research 847,959 816,528 31,431 93.395 Cancer Treatment Research 438,349 439,286 (937) 93.396 Cancer Biology Research 93,919 88,642 5,277 93.397 Cancer Centers Support Grants 15,552 14,078 1,474 93.667 Social Services Block Grant 19,619 27,170 (7,551) 93.837 Cardiovascular Diseases Research 193,160 188,850 4,310 93.838 Lung Diseases Research 482,934 471,427 11,507 93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research 1,075,493 1,035,041 40,452 93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders 1,645,025 1,596,611 48,414 93.855 Allergy, Immunology and Transplantation Research 73,869 72,630 1,239 93.859 Biomedical Research and Research Training 363,336 366,791 (3,455) 93.865 Child Health and Human Development Extramural Research 3,790,797 3,733,008 57,789 93.866 Aging Research 1,101,363 1,098,891 2,472 93.946 Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs 80,039 78,033 2,006 93.994 Maternal and Child Health Services Block Grant to the States 171,995 168,656 3,339 The Role of Oral Care in Nonventilator Hospital-Acquired Pneumonia (NVHAP) Prevention 148,388 – 148,388 Total $ 13,864,545 $ 13,482,752 $ 381,793 Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should implement internal controls to ensure amounts are appropriately accumulated and reported on the Schedule and all federal expenditures are appropriately identified and reported on the Schedule. Views of responsible officials: Award amounts were changed on the Schedule after management’s review was executed. Management acknowledges that implementing the new Enterprise Resource Planning (ERP) system, in 2023 presented changes to the SEFA reporting. Management has identified and addressed the reporting issues within the new system to ensure that the grant totals are appropriately captured in the SEFA. Endeavor will enhance grant management award processes by revising its procedures and adding additional controls to monitor for accuracy of the core data. Management will reinforce the importance of timeliness and accuracy of the Schedule reporting totals to facilitate accurate reporting.
Finding 2023-001 – Reporting Information of the federal program: Federal Grantor: Department of Defense (DOD) Assistance Listing No.: 12.420, Military Medical Research and Development Pass-Through Grantor: Johns Hopkins University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.172, Human Genome Research Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.226, Research on Healthcare Costs, Quality and Outcomes Pass-Through Grantor: The Regents of the University of Michigan Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.242, Mental Health Research Grants Pass-Through Grantor: Rutgers State University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.307, Minority Health and Health Disparities Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.310, Trans-NIH Research Support Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.350, National Center for Advancing Translational Sciences Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.351, Research Infrastructure Program Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.361, Nursing Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.368, 21st Century Cures Act – Precision Medicine Initiative Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.394, Cancer Detection and Diagnosis Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.395, Cancer Treatment Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.396, Cancer Biology Research Pass-Through Grantor: Tulane University, Louisiana State University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.397, Cancer Centers Support Grants Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.667, Social Services Block Grant Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.837, Cardiovascular Diseases Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.838, Lung Diseases Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.847, Diabetes, Digestive, and Kidney Diseases Extramural Research Pass-Through Grantors: Northwestern University, Duke University, University of Washington, The Regents of University of Michigan Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.853, Extramural Research Programs in the Neurosciences and Neurological Disorders Pass-Through Grantor: Rush University Medical Center Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.855, Allergy, Immunology and Transplantation Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.859, Biomedical Research and Research Training Pass-Through Grantor: University of Wisconsin – Madison Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.865, Child Health and Human Development Extramural Research Pass-Through Grantors: Northwestern University, University of Washington, The Regents of the University of California Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.866, Aging Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.946, Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.994, Maternal and Child Health Services Block Grant to the States Pass-Through Grantor: Northwestern Memorial Hospital Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” The Uniform Guidance 2 CFR section 200.510 states, “(b) Schedule of expenditures of Federal awards. The auditee must also prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with §200.502 Basis for determining Federal awards expended.” Condition: Certain grants related to the Research and Development Cluster were misstated by $233,405 on the preliminary schedule of expenditures of federal awards (the Schedule) provided by management due to the inappropriate classification of costs within the general ledger; the final Schedule was corrected. In addition, an award which was not a federal grant award with expenditures of $148,388 was included on the preliminary Schedule provided by management. The final Schedule was corrected. Cause: Endeavor’s internal controls over the preparation of the Schedule were not sufficient to properly accumulate and accurately report all expenditures of federal awards. Effect or Potential Effect: Inaccurate or improper reporting of expenditures results in a misstated Schedule and can also potentially result in insufficient testing of the major programs or improper identification of major programs for audit purposes. Questioned costs: None. Context: The table below reflects the preliminary and adjusted assistance listing balances on the Schedule (only assistance listing programs which changed are included below): Assistance Listing No. Name of Federal Program Preliminary Schedule Adjusted Schedule Change 12.420 Military Medical Research and Development $ 241,025 $ 224,418 $ 16,607 93.172 Human Genome Research 14,874 15,121 (247) 93.226 Research on Healthcare Costs, Quality and Outcomes 251,325 248,842 2,483 93.242 Mental Health Research Grants 1,616,503 1,617,376 (873) 93.307 Minority Health and Health Disparities Research 17,323 15,122 2,201 93.310 Trans-NIH Research Support 313,459 313,490 (31) 93.350 National Center for Advancing Translational Sciences 516,734 518,429 (1,695) 93.351 Research Infrastructure Program 242,436 232,058 10,378 93.361 Nursing Research 8,745 7,645 1,100 93.368 21st Century Cures Act – Precision Medicine Initiative 100,324 94,609 5,715 93.394 Cancer Detection and Diagnosis Research 847,959 816,528 31,431 93.395 Cancer Treatment Research 438,349 439,286 (937) 93.396 Cancer Biology Research 93,919 88,642 5,277 93.397 Cancer Centers Support Grants 15,552 14,078 1,474 93.667 Social Services Block Grant 19,619 27,170 (7,551) 93.837 Cardiovascular Diseases Research 193,160 188,850 4,310 93.838 Lung Diseases Research 482,934 471,427 11,507 93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research 1,075,493 1,035,041 40,452 93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders 1,645,025 1,596,611 48,414 93.855 Allergy, Immunology and Transplantation Research 73,869 72,630 1,239 93.859 Biomedical Research and Research Training 363,336 366,791 (3,455) 93.865 Child Health and Human Development Extramural Research 3,790,797 3,733,008 57,789 93.866 Aging Research 1,101,363 1,098,891 2,472 93.946 Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs 80,039 78,033 2,006 93.994 Maternal and Child Health Services Block Grant to the States 171,995 168,656 3,339 The Role of Oral Care in Nonventilator Hospital-Acquired Pneumonia (NVHAP) Prevention 148,388 – 148,388 Total $ 13,864,545 $ 13,482,752 $ 381,793 Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should implement internal controls to ensure amounts are appropriately accumulated and reported on the Schedule and all federal expenditures are appropriately identified and reported on the Schedule. Views of responsible officials: Award amounts were changed on the Schedule after management’s review was executed. Management acknowledges that implementing the new Enterprise Resource Planning (ERP) system, in 2023 presented changes to the SEFA reporting. Management has identified and addressed the reporting issues within the new system to ensure that the grant totals are appropriately captured in the SEFA. Endeavor will enhance grant management award processes by revising its procedures and adding additional controls to monitor for accuracy of the core data. Management will reinforce the importance of timeliness and accuracy of the Schedule reporting totals to facilitate accurate reporting.
Finding 2023-001 – Reporting Information of the federal program: Federal Grantor: Department of Defense (DOD) Assistance Listing No.: 12.420, Military Medical Research and Development Pass-Through Grantor: Johns Hopkins University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.172, Human Genome Research Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.226, Research on Healthcare Costs, Quality and Outcomes Pass-Through Grantor: The Regents of the University of Michigan Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.242, Mental Health Research Grants Pass-Through Grantor: Rutgers State University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.307, Minority Health and Health Disparities Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.310, Trans-NIH Research Support Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.350, National Center for Advancing Translational Sciences Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.351, Research Infrastructure Program Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.361, Nursing Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.368, 21st Century Cures Act – Precision Medicine Initiative Pass-Through Grantor: University of Chicago Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.394, Cancer Detection and Diagnosis Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.395, Cancer Treatment Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.396, Cancer Biology Research Pass-Through Grantor: Tulane University, Louisiana State University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.397, Cancer Centers Support Grants Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.667, Social Services Block Grant Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.837, Cardiovascular Diseases Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.838, Lung Diseases Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.847, Diabetes, Digestive, and Kidney Diseases Extramural Research Pass-Through Grantors: Northwestern University, Duke University, University of Washington, The Regents of University of Michigan Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.853, Extramural Research Programs in the Neurosciences and Neurological Disorders Pass-Through Grantor: Rush University Medical Center Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.855, Allergy, Immunology and Transplantation Research Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.859, Biomedical Research and Research Training Pass-Through Grantor: University of Wisconsin – Madison Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.865, Child Health and Human Development Extramural Research Pass-Through Grantors: Northwestern University, University of Washington, The Regents of the University of California Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.866, Aging Research Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.946, Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs Pass-Through Grantor: Northwestern University Federal Grantor: United States Department of Health and Human Services (HHS) Assistance Listing No.: 93.994, Maternal and Child Health Services Block Grant to the States Pass-Through Grantor: Northwestern Memorial Hospital Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” The Uniform Guidance 2 CFR section 200.510 states, “(b) Schedule of expenditures of Federal awards. The auditee must also prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with §200.502 Basis for determining Federal awards expended.” Condition: Certain grants related to the Research and Development Cluster were misstated by $233,405 on the preliminary schedule of expenditures of federal awards (the Schedule) provided by management due to the inappropriate classification of costs within the general ledger; the final Schedule was corrected. In addition, an award which was not a federal grant award with expenditures of $148,388 was included on the preliminary Schedule provided by management. The final Schedule was corrected. Cause: Endeavor’s internal controls over the preparation of the Schedule were not sufficient to properly accumulate and accurately report all expenditures of federal awards. Effect or Potential Effect: Inaccurate or improper reporting of expenditures results in a misstated Schedule and can also potentially result in insufficient testing of the major programs or improper identification of major programs for audit purposes. Questioned costs: None. Context: The table below reflects the preliminary and adjusted assistance listing balances on the Schedule (only assistance listing programs which changed are included below): Assistance Listing No. Name of Federal Program Preliminary Schedule Adjusted Schedule Change 12.420 Military Medical Research and Development $ 241,025 $ 224,418 $ 16,607 93.172 Human Genome Research 14,874 15,121 (247) 93.226 Research on Healthcare Costs, Quality and Outcomes 251,325 248,842 2,483 93.242 Mental Health Research Grants 1,616,503 1,617,376 (873) 93.307 Minority Health and Health Disparities Research 17,323 15,122 2,201 93.310 Trans-NIH Research Support 313,459 313,490 (31) 93.350 National Center for Advancing Translational Sciences 516,734 518,429 (1,695) 93.351 Research Infrastructure Program 242,436 232,058 10,378 93.361 Nursing Research 8,745 7,645 1,100 93.368 21st Century Cures Act – Precision Medicine Initiative 100,324 94,609 5,715 93.394 Cancer Detection and Diagnosis Research 847,959 816,528 31,431 93.395 Cancer Treatment Research 438,349 439,286 (937) 93.396 Cancer Biology Research 93,919 88,642 5,277 93.397 Cancer Centers Support Grants 15,552 14,078 1,474 93.667 Social Services Block Grant 19,619 27,170 (7,551) 93.837 Cardiovascular Diseases Research 193,160 188,850 4,310 93.838 Lung Diseases Research 482,934 471,427 11,507 93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research 1,075,493 1,035,041 40,452 93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders 1,645,025 1,596,611 48,414 93.855 Allergy, Immunology and Transplantation Research 73,869 72,630 1,239 93.859 Biomedical Research and Research Training 363,336 366,791 (3,455) 93.865 Child Health and Human Development Extramural Research 3,790,797 3,733,008 57,789 93.866 Aging Research 1,101,363 1,098,891 2,472 93.946 Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs 80,039 78,033 2,006 93.994 Maternal and Child Health Services Block Grant to the States 171,995 168,656 3,339 The Role of Oral Care in Nonventilator Hospital-Acquired Pneumonia (NVHAP) Prevention 148,388 – 148,388 Total $ 13,864,545 $ 13,482,752 $ 381,793 Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should implement internal controls to ensure amounts are appropriately accumulated and reported on the Schedule and all federal expenditures are appropriately identified and reported on the Schedule. Views of responsible officials: Award amounts were changed on the Schedule after management’s review was executed. Management acknowledges that implementing the new Enterprise Resource Planning (ERP) system, in 2023 presented changes to the SEFA reporting. Management has identified and addressed the reporting issues within the new system to ensure that the grant totals are appropriately captured in the SEFA. Endeavor will enhance grant management award processes by revising its procedures and adding additional controls to monitor for accuracy of the core data. Management will reinforce the importance of timeliness and accuracy of the Schedule reporting totals to facilitate accurate reporting.