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.
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.
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.
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.
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.
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 2023-002 – SEFA Reporting Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALNs: 21.027 93.778 93.914 Federal Agency: U.S. Department of Treasury U.S. Department of Health and Human Services Federal Award Years: January 1, 2023 – December 31, 2023 Criteria: 2 CFR, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart F, §200.510(b) requires that auditees 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. Condition Found, Including Perspective: The Schedule of Expenditures of Federal Awards (SEFA) prepared by management contained certain differences between federal expenditures reported and the years in which the federal awards were expended totaling $2,790,267 related to the COVID-10 Coronavirus State and Local Fiscal Recovery Funds, $174,977 related to the Medicaid Assistance Program and $250,808 relate to the HIV Emergency Relief Project Grants. Possible Cause and Effect: While the System performs a review during the compilation of the SEFA, controls were not designed or implemented effectively to ensure that certain amounts were properly reflected on the SEFA in the period in which they were expended. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: This is not a repeat finding. Recommendation We recommend that management implement appropriate controls and processes to ensure that expenditures are presented on the correct SEFA year. Views of Responsible Officials: Grady Memorial Hospital Corporation will implement a control and process to ensure that expenditures are properly reflected on the SEFA.
Finding 2023-002 – SEFA Reporting Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALNs: 21.027 93.778 93.914 Federal Agency: U.S. Department of Treasury U.S. Department of Health and Human Services Federal Award Years: January 1, 2023 – December 31, 2023 Criteria: 2 CFR, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart F, §200.510(b) requires that auditees 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. Condition Found, Including Perspective: The Schedule of Expenditures of Federal Awards (SEFA) prepared by management contained certain differences between federal expenditures reported and the years in which the federal awards were expended totaling $2,790,267 related to the COVID-10 Coronavirus State and Local Fiscal Recovery Funds, $174,977 related to the Medicaid Assistance Program and $250,808 relate to the HIV Emergency Relief Project Grants. Possible Cause and Effect: While the System performs a review during the compilation of the SEFA, controls were not designed or implemented effectively to ensure that certain amounts were properly reflected on the SEFA in the period in which they were expended. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: This is not a repeat finding. Recommendation We recommend that management implement appropriate controls and processes to ensure that expenditures are presented on the correct SEFA year. Views of Responsible Officials: Grady Memorial Hospital Corporation will implement a control and process to ensure that expenditures are properly reflected on the SEFA.
Finding 2023-002 – SEFA Reporting Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALNs: 21.027 93.778 93.914 Federal Agency: U.S. Department of Treasury U.S. Department of Health and Human Services Federal Award Years: January 1, 2023 – December 31, 2023 Criteria: 2 CFR, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart F, §200.510(b) requires that auditees 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. Condition Found, Including Perspective: The Schedule of Expenditures of Federal Awards (SEFA) prepared by management contained certain differences between federal expenditures reported and the years in which the federal awards were expended totaling $2,790,267 related to the COVID-10 Coronavirus State and Local Fiscal Recovery Funds, $174,977 related to the Medicaid Assistance Program and $250,808 relate to the HIV Emergency Relief Project Grants. Possible Cause and Effect: While the System performs a review during the compilation of the SEFA, controls were not designed or implemented effectively to ensure that certain amounts were properly reflected on the SEFA in the period in which they were expended. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: This is not a repeat finding. Recommendation We recommend that management implement appropriate controls and processes to ensure that expenditures are presented on the correct SEFA year. Views of Responsible Officials: Grady Memorial Hospital Corporation will implement a control and process to ensure that expenditures are properly reflected on the SEFA.
Finding 2023-002 – SEFA Reporting Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALNs: 21.027 93.778 93.914 Federal Agency: U.S. Department of Treasury U.S. Department of Health and Human Services Federal Award Years: January 1, 2023 – December 31, 2023 Criteria: 2 CFR, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart F, §200.510(b) requires that auditees 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. Condition Found, Including Perspective: The Schedule of Expenditures of Federal Awards (SEFA) prepared by management contained certain differences between federal expenditures reported and the years in which the federal awards were expended totaling $2,790,267 related to the COVID-10 Coronavirus State and Local Fiscal Recovery Funds, $174,977 related to the Medicaid Assistance Program and $250,808 relate to the HIV Emergency Relief Project Grants. Possible Cause and Effect: While the System performs a review during the compilation of the SEFA, controls were not designed or implemented effectively to ensure that certain amounts were properly reflected on the SEFA in the period in which they were expended. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: This is not a repeat finding. Recommendation We recommend that management implement appropriate controls and processes to ensure that expenditures are presented on the correct SEFA year. Views of Responsible Officials: Grady Memorial Hospital Corporation will implement a control and process to ensure that expenditures are properly reflected on the SEFA.
Finding 2023-002 – SEFA Reporting Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALNs: 21.027 93.778 93.914 Federal Agency: U.S. Department of Treasury U.S. Department of Health and Human Services Federal Award Years: January 1, 2023 – December 31, 2023 Criteria: 2 CFR, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart F, §200.510(b) requires that auditees 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. Condition Found, Including Perspective: The Schedule of Expenditures of Federal Awards (SEFA) prepared by management contained certain differences between federal expenditures reported and the years in which the federal awards were expended totaling $2,790,267 related to the COVID-10 Coronavirus State and Local Fiscal Recovery Funds, $174,977 related to the Medicaid Assistance Program and $250,808 relate to the HIV Emergency Relief Project Grants. Possible Cause and Effect: While the System performs a review during the compilation of the SEFA, controls were not designed or implemented effectively to ensure that certain amounts were properly reflected on the SEFA in the period in which they were expended. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: This is not a repeat finding. Recommendation We recommend that management implement appropriate controls and processes to ensure that expenditures are presented on the correct SEFA year. Views of Responsible Officials: Grady Memorial Hospital Corporation will implement a control and process to ensure that expenditures are properly reflected on the SEFA.
Finding 2023-002 – SEFA Reporting Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALNs: 21.027 93.778 93.914 Federal Agency: U.S. Department of Treasury U.S. Department of Health and Human Services Federal Award Years: January 1, 2023 – December 31, 2023 Criteria: 2 CFR, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart F, §200.510(b) requires that auditees 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. Condition Found, Including Perspective: The Schedule of Expenditures of Federal Awards (SEFA) prepared by management contained certain differences between federal expenditures reported and the years in which the federal awards were expended totaling $2,790,267 related to the COVID-10 Coronavirus State and Local Fiscal Recovery Funds, $174,977 related to the Medicaid Assistance Program and $250,808 relate to the HIV Emergency Relief Project Grants. Possible Cause and Effect: While the System performs a review during the compilation of the SEFA, controls were not designed or implemented effectively to ensure that certain amounts were properly reflected on the SEFA in the period in which they were expended. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: This is not a repeat finding. Recommendation We recommend that management implement appropriate controls and processes to ensure that expenditures are presented on the correct SEFA year. Views of Responsible Officials: Grady Memorial Hospital Corporation will implement a control and process to ensure that expenditures are properly reflected on the SEFA.
Finding 2023-002 – SEFA Reporting Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALNs: 21.027 93.778 93.914 Federal Agency: U.S. Department of Treasury U.S. Department of Health and Human Services Federal Award Years: January 1, 2023 – December 31, 2023 Criteria: 2 CFR, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart F, §200.510(b) requires that auditees 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. Condition Found, Including Perspective: The Schedule of Expenditures of Federal Awards (SEFA) prepared by management contained certain differences between federal expenditures reported and the years in which the federal awards were expended totaling $2,790,267 related to the COVID-10 Coronavirus State and Local Fiscal Recovery Funds, $174,977 related to the Medicaid Assistance Program and $250,808 relate to the HIV Emergency Relief Project Grants. Possible Cause and Effect: While the System performs a review during the compilation of the SEFA, controls were not designed or implemented effectively to ensure that certain amounts were properly reflected on the SEFA in the period in which they were expended. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: This is not a repeat finding. Recommendation We recommend that management implement appropriate controls and processes to ensure that expenditures are presented on the correct SEFA year. Views of Responsible Officials: Grady Memorial Hospital Corporation will implement a control and process to ensure that expenditures are properly reflected on the SEFA.
Finding 2023-002 – SEFA Reporting Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALNs: 21.027 93.778 93.914 Federal Agency: U.S. Department of Treasury U.S. Department of Health and Human Services Federal Award Years: January 1, 2023 – December 31, 2023 Criteria: 2 CFR, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart F, §200.510(b) requires that auditees 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. Condition Found, Including Perspective: The Schedule of Expenditures of Federal Awards (SEFA) prepared by management contained certain differences between federal expenditures reported and the years in which the federal awards were expended totaling $2,790,267 related to the COVID-10 Coronavirus State and Local Fiscal Recovery Funds, $174,977 related to the Medicaid Assistance Program and $250,808 relate to the HIV Emergency Relief Project Grants. Possible Cause and Effect: While the System performs a review during the compilation of the SEFA, controls were not designed or implemented effectively to ensure that certain amounts were properly reflected on the SEFA in the period in which they were expended. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: This is not a repeat finding. Recommendation We recommend that management implement appropriate controls and processes to ensure that expenditures are presented on the correct SEFA year. Views of Responsible Officials: Grady Memorial Hospital Corporation will implement a control and process to ensure that expenditures are properly reflected on the SEFA.
Finding 2023-002 – SEFA Reporting Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALNs: 21.027 93.778 93.914 Federal Agency: U.S. Department of Treasury U.S. Department of Health and Human Services Federal Award Years: January 1, 2023 – December 31, 2023 Criteria: 2 CFR, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart F, §200.510(b) requires that auditees 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. Condition Found, Including Perspective: The Schedule of Expenditures of Federal Awards (SEFA) prepared by management contained certain differences between federal expenditures reported and the years in which the federal awards were expended totaling $2,790,267 related to the COVID-10 Coronavirus State and Local Fiscal Recovery Funds, $174,977 related to the Medicaid Assistance Program and $250,808 relate to the HIV Emergency Relief Project Grants. Possible Cause and Effect: While the System performs a review during the compilation of the SEFA, controls were not designed or implemented effectively to ensure that certain amounts were properly reflected on the SEFA in the period in which they were expended. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: This is not a repeat finding. Recommendation We recommend that management implement appropriate controls and processes to ensure that expenditures are presented on the correct SEFA year. Views of Responsible Officials: Grady Memorial Hospital Corporation will implement a control and process to ensure that expenditures are properly reflected on the SEFA.
Finding Number: 2023-008 Repeat Finding: No Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Description: Schedule of Expenditures of Federal Awards Awareness and Preparation Major Programs: AL#93.243 - Substance Abuse and Mental Health Services – Direct Award (DHHS) – Award numbers: 1H79SM087536-01, 1H79SM087590-01, 5H79SP081724-04, 5H79SP081724-05, 5H79SM082160-04, 5H79SM082160-05, 5H79SP082229-02, 5H79SP082229-03, 1H79SM088765-01, 1H79TI085542-01, H79TI086128-01 and CD9-23-4425 AL#93.738 – PPHF: Racial and Ethnic Approaches to Community Health Program financed solely by Public Prevention and Health Funds – Direct Award (DHHS) – Award number: 5 NU58DP006960-02-00 and 6 NU58DP006960-01-01 AL#93.772 - Tribal Public Health Capacity Building and Quality Improvement Umbrella Cooperative Agreement – Direct Award (DHHS) – Award numbers: 1 NU38TO000023-01-00, 6 NU38TO000023-01-01, 6 NU38OT000257-05-03 and 6 NU38OT000257C3 AL#93.788 – Opioid STR – Direct Award (DHHS) – Award numbers: 1H79TI083088-01, 5H79TI083088-02, 6H79TI085684-01M003 and CD9-23-4425 AL#93.859 – Biomedical Research and Research Training – Direct Award (DHHS) – Award numbers: 5S06GM142115-02 and 5S06GM142115-03 Questioned Costs: None How the questioned costs were computed: N/A Compliance Requirement: Reporting Condition: The Organization did not have all federal expenditures recorded in their trial balance and did not have accurate records of all expenditures spent during the audit period. In addition, it did not have all of the necessary information or training to create the Schedule of Expenditures of Federal Awards. Criteria: Under 2 CFR Part 200.502, the auditee must prepare the Schedule of Expenditure of Federal Awards to cover the appropriate audit period and to include all applicable federal expenditures expended during the audit period. Cause: The Organization does not have processes in place to properly track award numbers, award periods, assistance listing numbers and grant spending. Effect: The Organization was unable to provide the auditors with a complete Schedule of Expenditures of Federal Awards (including all grants with federal awards, all assistance listing numbers, total amount of federal awards expended) and could not verify the completeness of expenditures recorded in their financial statements provided for the audit. Recommendation: We recommend the Organization create processes and procedures that capture all federal funding received and track applicable expenditures. This report should be reconciled regularly (at least monthly) when requests for reimbursement are made and should include all applicable information necessary to identify the funding agency, assistance listing number, and any other pertinent passthrough information. With this process in place, the Organization will be better able to track and monitor grant funding, plan future projects or future funding needs, and prepare for the annual audit. Views of Responsible Officials: Management agrees with the finding and has committed to a corrective action plan.
Finding Number: 2023-008 Repeat Finding: No Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Description: Schedule of Expenditures of Federal Awards Awareness and Preparation Major Programs: AL#93.243 - Substance Abuse and Mental Health Services – Direct Award (DHHS) – Award numbers: 1H79SM087536-01, 1H79SM087590-01, 5H79SP081724-04, 5H79SP081724-05, 5H79SM082160-04, 5H79SM082160-05, 5H79SP082229-02, 5H79SP082229-03, 1H79SM088765-01, 1H79TI085542-01, H79TI086128-01 and CD9-23-4425 AL#93.738 – PPHF: Racial and Ethnic Approaches to Community Health Program financed solely by Public Prevention and Health Funds – Direct Award (DHHS) – Award number: 5 NU58DP006960-02-00 and 6 NU58DP006960-01-01 AL#93.772 - Tribal Public Health Capacity Building and Quality Improvement Umbrella Cooperative Agreement – Direct Award (DHHS) – Award numbers: 1 NU38TO000023-01-00, 6 NU38TO000023-01-01, 6 NU38OT000257-05-03 and 6 NU38OT000257C3 AL#93.788 – Opioid STR – Direct Award (DHHS) – Award numbers: 1H79TI083088-01, 5H79TI083088-02, 6H79TI085684-01M003 and CD9-23-4425 AL#93.859 – Biomedical Research and Research Training – Direct Award (DHHS) – Award numbers: 5S06GM142115-02 and 5S06GM142115-03 Questioned Costs: None How the questioned costs were computed: N/A Compliance Requirement: Reporting Condition: The Organization did not have all federal expenditures recorded in their trial balance and did not have accurate records of all expenditures spent during the audit period. In addition, it did not have all of the necessary information or training to create the Schedule of Expenditures of Federal Awards. Criteria: Under 2 CFR Part 200.502, the auditee must prepare the Schedule of Expenditure of Federal Awards to cover the appropriate audit period and to include all applicable federal expenditures expended during the audit period. Cause: The Organization does not have processes in place to properly track award numbers, award periods, assistance listing numbers and grant spending. Effect: The Organization was unable to provide the auditors with a complete Schedule of Expenditures of Federal Awards (including all grants with federal awards, all assistance listing numbers, total amount of federal awards expended) and could not verify the completeness of expenditures recorded in their financial statements provided for the audit. Recommendation: We recommend the Organization create processes and procedures that capture all federal funding received and track applicable expenditures. This report should be reconciled regularly (at least monthly) when requests for reimbursement are made and should include all applicable information necessary to identify the funding agency, assistance listing number, and any other pertinent passthrough information. With this process in place, the Organization will be better able to track and monitor grant funding, plan future projects or future funding needs, and prepare for the annual audit. Views of Responsible Officials: Management agrees with the finding and has committed to a corrective action plan.
Finding Number: 2023-008 Repeat Finding: No Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Description: Schedule of Expenditures of Federal Awards Awareness and Preparation Major Programs: AL#93.243 - Substance Abuse and Mental Health Services – Direct Award (DHHS) – Award numbers: 1H79SM087536-01, 1H79SM087590-01, 5H79SP081724-04, 5H79SP081724-05, 5H79SM082160-04, 5H79SM082160-05, 5H79SP082229-02, 5H79SP082229-03, 1H79SM088765-01, 1H79TI085542-01, H79TI086128-01 and CD9-23-4425 AL#93.738 – PPHF: Racial and Ethnic Approaches to Community Health Program financed solely by Public Prevention and Health Funds – Direct Award (DHHS) – Award number: 5 NU58DP006960-02-00 and 6 NU58DP006960-01-01 AL#93.772 - Tribal Public Health Capacity Building and Quality Improvement Umbrella Cooperative Agreement – Direct Award (DHHS) – Award numbers: 1 NU38TO000023-01-00, 6 NU38TO000023-01-01, 6 NU38OT000257-05-03 and 6 NU38OT000257C3 AL#93.788 – Opioid STR – Direct Award (DHHS) – Award numbers: 1H79TI083088-01, 5H79TI083088-02, 6H79TI085684-01M003 and CD9-23-4425 AL#93.859 – Biomedical Research and Research Training – Direct Award (DHHS) – Award numbers: 5S06GM142115-02 and 5S06GM142115-03 Questioned Costs: None How the questioned costs were computed: N/A Compliance Requirement: Reporting Condition: The Organization did not have all federal expenditures recorded in their trial balance and did not have accurate records of all expenditures spent during the audit period. In addition, it did not have all of the necessary information or training to create the Schedule of Expenditures of Federal Awards. Criteria: Under 2 CFR Part 200.502, the auditee must prepare the Schedule of Expenditure of Federal Awards to cover the appropriate audit period and to include all applicable federal expenditures expended during the audit period. Cause: The Organization does not have processes in place to properly track award numbers, award periods, assistance listing numbers and grant spending. Effect: The Organization was unable to provide the auditors with a complete Schedule of Expenditures of Federal Awards (including all grants with federal awards, all assistance listing numbers, total amount of federal awards expended) and could not verify the completeness of expenditures recorded in their financial statements provided for the audit. Recommendation: We recommend the Organization create processes and procedures that capture all federal funding received and track applicable expenditures. This report should be reconciled regularly (at least monthly) when requests for reimbursement are made and should include all applicable information necessary to identify the funding agency, assistance listing number, and any other pertinent passthrough information. With this process in place, the Organization will be better able to track and monitor grant funding, plan future projects or future funding needs, and prepare for the annual audit. Views of Responsible Officials: Management agrees with the finding and has committed to a corrective action plan.
Finding Number: 2023-008 Repeat Finding: No Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Description: Schedule of Expenditures of Federal Awards Awareness and Preparation Major Programs: AL#93.243 - Substance Abuse and Mental Health Services – Direct Award (DHHS) – Award numbers: 1H79SM087536-01, 1H79SM087590-01, 5H79SP081724-04, 5H79SP081724-05, 5H79SM082160-04, 5H79SM082160-05, 5H79SP082229-02, 5H79SP082229-03, 1H79SM088765-01, 1H79TI085542-01, H79TI086128-01 and CD9-23-4425 AL#93.738 – PPHF: Racial and Ethnic Approaches to Community Health Program financed solely by Public Prevention and Health Funds – Direct Award (DHHS) – Award number: 5 NU58DP006960-02-00 and 6 NU58DP006960-01-01 AL#93.772 - Tribal Public Health Capacity Building and Quality Improvement Umbrella Cooperative Agreement – Direct Award (DHHS) – Award numbers: 1 NU38TO000023-01-00, 6 NU38TO000023-01-01, 6 NU38OT000257-05-03 and 6 NU38OT000257C3 AL#93.788 – Opioid STR – Direct Award (DHHS) – Award numbers: 1H79TI083088-01, 5H79TI083088-02, 6H79TI085684-01M003 and CD9-23-4425 AL#93.859 – Biomedical Research and Research Training – Direct Award (DHHS) – Award numbers: 5S06GM142115-02 and 5S06GM142115-03 Questioned Costs: None How the questioned costs were computed: N/A Compliance Requirement: Reporting Condition: The Organization did not have all federal expenditures recorded in their trial balance and did not have accurate records of all expenditures spent during the audit period. In addition, it did not have all of the necessary information or training to create the Schedule of Expenditures of Federal Awards. Criteria: Under 2 CFR Part 200.502, the auditee must prepare the Schedule of Expenditure of Federal Awards to cover the appropriate audit period and to include all applicable federal expenditures expended during the audit period. Cause: The Organization does not have processes in place to properly track award numbers, award periods, assistance listing numbers and grant spending. Effect: The Organization was unable to provide the auditors with a complete Schedule of Expenditures of Federal Awards (including all grants with federal awards, all assistance listing numbers, total amount of federal awards expended) and could not verify the completeness of expenditures recorded in their financial statements provided for the audit. Recommendation: We recommend the Organization create processes and procedures that capture all federal funding received and track applicable expenditures. This report should be reconciled regularly (at least monthly) when requests for reimbursement are made and should include all applicable information necessary to identify the funding agency, assistance listing number, and any other pertinent passthrough information. With this process in place, the Organization will be better able to track and monitor grant funding, plan future projects or future funding needs, and prepare for the annual audit. Views of Responsible Officials: Management agrees with the finding and has committed to a corrective action plan.
Finding Number: 2023-008 Repeat Finding: No Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Description: Schedule of Expenditures of Federal Awards Awareness and Preparation Major Programs: AL#93.243 - Substance Abuse and Mental Health Services – Direct Award (DHHS) – Award numbers: 1H79SM087536-01, 1H79SM087590-01, 5H79SP081724-04, 5H79SP081724-05, 5H79SM082160-04, 5H79SM082160-05, 5H79SP082229-02, 5H79SP082229-03, 1H79SM088765-01, 1H79TI085542-01, H79TI086128-01 and CD9-23-4425 AL#93.738 – PPHF: Racial and Ethnic Approaches to Community Health Program financed solely by Public Prevention and Health Funds – Direct Award (DHHS) – Award number: 5 NU58DP006960-02-00 and 6 NU58DP006960-01-01 AL#93.772 - Tribal Public Health Capacity Building and Quality Improvement Umbrella Cooperative Agreement – Direct Award (DHHS) – Award numbers: 1 NU38TO000023-01-00, 6 NU38TO000023-01-01, 6 NU38OT000257-05-03 and 6 NU38OT000257C3 AL#93.788 – Opioid STR – Direct Award (DHHS) – Award numbers: 1H79TI083088-01, 5H79TI083088-02, 6H79TI085684-01M003 and CD9-23-4425 AL#93.859 – Biomedical Research and Research Training – Direct Award (DHHS) – Award numbers: 5S06GM142115-02 and 5S06GM142115-03 Questioned Costs: None How the questioned costs were computed: N/A Compliance Requirement: Reporting Condition: The Organization did not have all federal expenditures recorded in their trial balance and did not have accurate records of all expenditures spent during the audit period. In addition, it did not have all of the necessary information or training to create the Schedule of Expenditures of Federal Awards. Criteria: Under 2 CFR Part 200.502, the auditee must prepare the Schedule of Expenditure of Federal Awards to cover the appropriate audit period and to include all applicable federal expenditures expended during the audit period. Cause: The Organization does not have processes in place to properly track award numbers, award periods, assistance listing numbers and grant spending. Effect: The Organization was unable to provide the auditors with a complete Schedule of Expenditures of Federal Awards (including all grants with federal awards, all assistance listing numbers, total amount of federal awards expended) and could not verify the completeness of expenditures recorded in their financial statements provided for the audit. Recommendation: We recommend the Organization create processes and procedures that capture all federal funding received and track applicable expenditures. This report should be reconciled regularly (at least monthly) when requests for reimbursement are made and should include all applicable information necessary to identify the funding agency, assistance listing number, and any other pertinent passthrough information. With this process in place, the Organization will be better able to track and monitor grant funding, plan future projects or future funding needs, and prepare for the annual audit. Views of Responsible Officials: Management agrees with the finding and has committed to a corrective action plan.
Finding Number: 2023-008 Repeat Finding: No Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Description: Schedule of Expenditures of Federal Awards Awareness and Preparation Major Programs: AL#93.243 - Substance Abuse and Mental Health Services – Direct Award (DHHS) – Award numbers: 1H79SM087536-01, 1H79SM087590-01, 5H79SP081724-04, 5H79SP081724-05, 5H79SM082160-04, 5H79SM082160-05, 5H79SP082229-02, 5H79SP082229-03, 1H79SM088765-01, 1H79TI085542-01, H79TI086128-01 and CD9-23-4425 AL#93.738 – PPHF: Racial and Ethnic Approaches to Community Health Program financed solely by Public Prevention and Health Funds – Direct Award (DHHS) – Award number: 5 NU58DP006960-02-00 and 6 NU58DP006960-01-01 AL#93.772 - Tribal Public Health Capacity Building and Quality Improvement Umbrella Cooperative Agreement – Direct Award (DHHS) – Award numbers: 1 NU38TO000023-01-00, 6 NU38TO000023-01-01, 6 NU38OT000257-05-03 and 6 NU38OT000257C3 AL#93.788 – Opioid STR – Direct Award (DHHS) – Award numbers: 1H79TI083088-01, 5H79TI083088-02, 6H79TI085684-01M003 and CD9-23-4425 AL#93.859 – Biomedical Research and Research Training – Direct Award (DHHS) – Award numbers: 5S06GM142115-02 and 5S06GM142115-03 Questioned Costs: None How the questioned costs were computed: N/A Compliance Requirement: Reporting Condition: The Organization did not have all federal expenditures recorded in their trial balance and did not have accurate records of all expenditures spent during the audit period. In addition, it did not have all of the necessary information or training to create the Schedule of Expenditures of Federal Awards. Criteria: Under 2 CFR Part 200.502, the auditee must prepare the Schedule of Expenditure of Federal Awards to cover the appropriate audit period and to include all applicable federal expenditures expended during the audit period. Cause: The Organization does not have processes in place to properly track award numbers, award periods, assistance listing numbers and grant spending. Effect: The Organization was unable to provide the auditors with a complete Schedule of Expenditures of Federal Awards (including all grants with federal awards, all assistance listing numbers, total amount of federal awards expended) and could not verify the completeness of expenditures recorded in their financial statements provided for the audit. Recommendation: We recommend the Organization create processes and procedures that capture all federal funding received and track applicable expenditures. This report should be reconciled regularly (at least monthly) when requests for reimbursement are made and should include all applicable information necessary to identify the funding agency, assistance listing number, and any other pertinent passthrough information. With this process in place, the Organization will be better able to track and monitor grant funding, plan future projects or future funding needs, and prepare for the annual audit. Views of Responsible Officials: Management agrees with the finding and has committed to a corrective action plan.
Finding Number: 2023-008 Repeat Finding: No Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Description: Schedule of Expenditures of Federal Awards Awareness and Preparation Major Programs: AL#93.243 - Substance Abuse and Mental Health Services – Direct Award (DHHS) – Award numbers: 1H79SM087536-01, 1H79SM087590-01, 5H79SP081724-04, 5H79SP081724-05, 5H79SM082160-04, 5H79SM082160-05, 5H79SP082229-02, 5H79SP082229-03, 1H79SM088765-01, 1H79TI085542-01, H79TI086128-01 and CD9-23-4425 AL#93.738 – PPHF: Racial and Ethnic Approaches to Community Health Program financed solely by Public Prevention and Health Funds – Direct Award (DHHS) – Award number: 5 NU58DP006960-02-00 and 6 NU58DP006960-01-01 AL#93.772 - Tribal Public Health Capacity Building and Quality Improvement Umbrella Cooperative Agreement – Direct Award (DHHS) – Award numbers: 1 NU38TO000023-01-00, 6 NU38TO000023-01-01, 6 NU38OT000257-05-03 and 6 NU38OT000257C3 AL#93.788 – Opioid STR – Direct Award (DHHS) – Award numbers: 1H79TI083088-01, 5H79TI083088-02, 6H79TI085684-01M003 and CD9-23-4425 AL#93.859 – Biomedical Research and Research Training – Direct Award (DHHS) – Award numbers: 5S06GM142115-02 and 5S06GM142115-03 Questioned Costs: None How the questioned costs were computed: N/A Compliance Requirement: Reporting Condition: The Organization did not have all federal expenditures recorded in their trial balance and did not have accurate records of all expenditures spent during the audit period. In addition, it did not have all of the necessary information or training to create the Schedule of Expenditures of Federal Awards. Criteria: Under 2 CFR Part 200.502, the auditee must prepare the Schedule of Expenditure of Federal Awards to cover the appropriate audit period and to include all applicable federal expenditures expended during the audit period. Cause: The Organization does not have processes in place to properly track award numbers, award periods, assistance listing numbers and grant spending. Effect: The Organization was unable to provide the auditors with a complete Schedule of Expenditures of Federal Awards (including all grants with federal awards, all assistance listing numbers, total amount of federal awards expended) and could not verify the completeness of expenditures recorded in their financial statements provided for the audit. Recommendation: We recommend the Organization create processes and procedures that capture all federal funding received and track applicable expenditures. This report should be reconciled regularly (at least monthly) when requests for reimbursement are made and should include all applicable information necessary to identify the funding agency, assistance listing number, and any other pertinent passthrough information. With this process in place, the Organization will be better able to track and monitor grant funding, plan future projects or future funding needs, and prepare for the annual audit. Views of Responsible Officials: Management agrees with the finding and has committed to a corrective action plan.
Finding Number: 2023-008 Repeat Finding: No Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Description: Schedule of Expenditures of Federal Awards Awareness and Preparation Major Programs: AL#93.243 - Substance Abuse and Mental Health Services – Direct Award (DHHS) – Award numbers: 1H79SM087536-01, 1H79SM087590-01, 5H79SP081724-04, 5H79SP081724-05, 5H79SM082160-04, 5H79SM082160-05, 5H79SP082229-02, 5H79SP082229-03, 1H79SM088765-01, 1H79TI085542-01, H79TI086128-01 and CD9-23-4425 AL#93.738 – PPHF: Racial and Ethnic Approaches to Community Health Program financed solely by Public Prevention and Health Funds – Direct Award (DHHS) – Award number: 5 NU58DP006960-02-00 and 6 NU58DP006960-01-01 AL#93.772 - Tribal Public Health Capacity Building and Quality Improvement Umbrella Cooperative Agreement – Direct Award (DHHS) – Award numbers: 1 NU38TO000023-01-00, 6 NU38TO000023-01-01, 6 NU38OT000257-05-03 and 6 NU38OT000257C3 AL#93.788 – Opioid STR – Direct Award (DHHS) – Award numbers: 1H79TI083088-01, 5H79TI083088-02, 6H79TI085684-01M003 and CD9-23-4425 AL#93.859 – Biomedical Research and Research Training – Direct Award (DHHS) – Award numbers: 5S06GM142115-02 and 5S06GM142115-03 Questioned Costs: None How the questioned costs were computed: N/A Compliance Requirement: Reporting Condition: The Organization did not have all federal expenditures recorded in their trial balance and did not have accurate records of all expenditures spent during the audit period. In addition, it did not have all of the necessary information or training to create the Schedule of Expenditures of Federal Awards. Criteria: Under 2 CFR Part 200.502, the auditee must prepare the Schedule of Expenditure of Federal Awards to cover the appropriate audit period and to include all applicable federal expenditures expended during the audit period. Cause: The Organization does not have processes in place to properly track award numbers, award periods, assistance listing numbers and grant spending. Effect: The Organization was unable to provide the auditors with a complete Schedule of Expenditures of Federal Awards (including all grants with federal awards, all assistance listing numbers, total amount of federal awards expended) and could not verify the completeness of expenditures recorded in their financial statements provided for the audit. Recommendation: We recommend the Organization create processes and procedures that capture all federal funding received and track applicable expenditures. This report should be reconciled regularly (at least monthly) when requests for reimbursement are made and should include all applicable information necessary to identify the funding agency, assistance listing number, and any other pertinent passthrough information. With this process in place, the Organization will be better able to track and monitor grant funding, plan future projects or future funding needs, and prepare for the annual audit. Views of Responsible Officials: Management agrees with the finding and has committed to a corrective action plan.
Finding Number: 2023-008 Repeat Finding: No Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Description: Schedule of Expenditures of Federal Awards Awareness and Preparation Major Programs: AL#93.243 - Substance Abuse and Mental Health Services – Direct Award (DHHS) – Award numbers: 1H79SM087536-01, 1H79SM087590-01, 5H79SP081724-04, 5H79SP081724-05, 5H79SM082160-04, 5H79SM082160-05, 5H79SP082229-02, 5H79SP082229-03, 1H79SM088765-01, 1H79TI085542-01, H79TI086128-01 and CD9-23-4425 AL#93.738 – PPHF: Racial and Ethnic Approaches to Community Health Program financed solely by Public Prevention and Health Funds – Direct Award (DHHS) – Award number: 5 NU58DP006960-02-00 and 6 NU58DP006960-01-01 AL#93.772 - Tribal Public Health Capacity Building and Quality Improvement Umbrella Cooperative Agreement – Direct Award (DHHS) – Award numbers: 1 NU38TO000023-01-00, 6 NU38TO000023-01-01, 6 NU38OT000257-05-03 and 6 NU38OT000257C3 AL#93.788 – Opioid STR – Direct Award (DHHS) – Award numbers: 1H79TI083088-01, 5H79TI083088-02, 6H79TI085684-01M003 and CD9-23-4425 AL#93.859 – Biomedical Research and Research Training – Direct Award (DHHS) – Award numbers: 5S06GM142115-02 and 5S06GM142115-03 Questioned Costs: None How the questioned costs were computed: N/A Compliance Requirement: Reporting Condition: The Organization did not have all federal expenditures recorded in their trial balance and did not have accurate records of all expenditures spent during the audit period. In addition, it did not have all of the necessary information or training to create the Schedule of Expenditures of Federal Awards. Criteria: Under 2 CFR Part 200.502, the auditee must prepare the Schedule of Expenditure of Federal Awards to cover the appropriate audit period and to include all applicable federal expenditures expended during the audit period. Cause: The Organization does not have processes in place to properly track award numbers, award periods, assistance listing numbers and grant spending. Effect: The Organization was unable to provide the auditors with a complete Schedule of Expenditures of Federal Awards (including all grants with federal awards, all assistance listing numbers, total amount of federal awards expended) and could not verify the completeness of expenditures recorded in their financial statements provided for the audit. Recommendation: We recommend the Organization create processes and procedures that capture all federal funding received and track applicable expenditures. This report should be reconciled regularly (at least monthly) when requests for reimbursement are made and should include all applicable information necessary to identify the funding agency, assistance listing number, and any other pertinent passthrough information. With this process in place, the Organization will be better able to track and monitor grant funding, plan future projects or future funding needs, and prepare for the annual audit. Views of Responsible Officials: Management agrees with the finding and has committed to a corrective action plan.
Program Information: Texas Statewide Youth Services Network Project (“SYSN”) (ALN #93.590) 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, did not originally bifurcate grant expenditures between state and federal funding sources for the SYSN grant. Cause: The Organization did not properly identify separate state and federal funding sources as stated on the Notice of Award for the grant. Effect or Potential Effect: The original draft SEFA did not properly present both state and federal programs for the SYSN grant. Questioned Costs: None. Context: During the process to prepare the draft SEFA, management did not properly identify separate funding sources for one grant resulting in improper presentation of certain federal expenditures as state expenditures on the draft SEFA. Identification as a Repeat Finding: No. Recommendation: We recommend that the Alliance enhance its procedures and internal controls with respect to the preparation and review of the SEFA by comparing programs on the SEFA with corresponding grant agreements and notices of award. Views of Responsible Officials and Planned Corrective Actions: Review all federal grant contracts to determine if any separate funding sources should be listed for total funds received.
Federal Program Information: Education Stabilization Fund (ALN 84.425U) Criteria: 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. Condition: During our audit of the financial statements for the fiscal year ending December 31, 2023, we identified that the SEFA was not prepared in accordance with the requirements set forth by the Uniform Guidance (2 CFR Part 200) and was incomplete. Cause: Insufficient internal control and administrative oversight. Effect or Potential Effect: As a result of the incorrect preparation, the SEFA did not accurately reflect the Federal awards expended during the fiscal year. This could potentially lead to non-compliance with Federal requirements and affect the accuracy of the financial statements. Recommendation: We recommend that the entity implement the following corrective actions: 1. Provide training to the staff responsible for preparing the SEFA to ensure they understand the requirements of the Uniform Guidance. 2. Establish a review process to verify the accuracy and completeness of the SEFA before submission. 3. Utilize a checklist or other tools to ensure all required information is included in the SEFA. Views of Responsible Officials: The Alliance will implement more stringent internal controls and administrative oversight with respect to preparation and review of the SEFA.
Federal Awards Findings and Questioned Costs Finding 2023-003 – Inaccurate SEFA - Reporting – Material Weakness Name of Federal Agency: U.S Department of Housing and Urban Development and U.S. Department of Treasury Federal Program Name: HOME Investments Partnership Program and Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 14.239 and 21.027 Federal Award Identification Number and Year: Identification number unavailable. Program years 2010, 2012, 2015, 2019, 2023. Name of Pass-through Entity (if applicable): Rhode Island Housing and Mortgage Finance Corporation and the City of Providence, Rhode Island. Criteria: In accordance with 2 CFR 200.302 (Financial Management), a grant recipient’s financial management system must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the federal statutes, regulations, and the terms and conditions of the federal award. In addition, 2 CFR 200.510 (Financial Statements), states in part that the auditee must 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 2CFR 200.502. At a minimum, the schedule must include: -All individual Federal programs by Federal agency. -For Federal awards received as a subrecipient, the name of the pass-through entity and identifying number assigned by the pass-through entity must be included. -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. -Include the total amount provided to subrecipients from each Federal program. Condition / Context: The Organization management’s review and approval process did not detect the errors that were identified during the audit procedures performed. The errors detected consisted of the understatement of Federal Assistance Listing Numbers 14.239 and 14.218 in the amounts of $364,207 and $295,000, respectively, and an overstatement of Federal Assistance Listing Number 21.027 in the amount of $66,320, for a total net understatement of $592,887. Cause: The Organization’s internal controls over the preparation and review of the SEFA were not operating effectively. Material audit adjustments were proposed during the course of the audit that lead to material changes to the SEFA. Effect or Potential Effect: Inadequate controls over the preparation of the SEFA could result in financial misstatements or potential noncompliance. Questioned Costs: None Identification as a Repeat Finding: This is a repeat finding for Assistance Listing Number 14.239. See 2022-003. Recommendation: We recommend the Organization strengthen its policies, procedures, and controls for the identification of federal awards to ensure a complete and accurate SEFA is prepared in a timely manner. Views of Responsible Officials: Management agrees with the finding and is in the process of revising internal controls to address SEFA preparation.
Federal Awards Findings and Questioned Costs Finding 2023-003 – Inaccurate SEFA - Reporting – Material Weakness Name of Federal Agency: U.S Department of Housing and Urban Development and U.S. Department of Treasury Federal Program Name: HOME Investments Partnership Program and Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 14.239 and 21.027 Federal Award Identification Number and Year: Identification number unavailable. Program years 2010, 2012, 2015, 2019, 2023. Name of Pass-through Entity (if applicable): Rhode Island Housing and Mortgage Finance Corporation and the City of Providence, Rhode Island. Criteria: In accordance with 2 CFR 200.302 (Financial Management), a grant recipient’s financial management system must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the federal statutes, regulations, and the terms and conditions of the federal award. In addition, 2 CFR 200.510 (Financial Statements), states in part that the auditee must 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 2CFR 200.502. At a minimum, the schedule must include: -All individual Federal programs by Federal agency. -For Federal awards received as a subrecipient, the name of the pass-through entity and identifying number assigned by the pass-through entity must be included. -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. -Include the total amount provided to subrecipients from each Federal program. Condition / Context: The Organization management’s review and approval process did not detect the errors that were identified during the audit procedures performed. The errors detected consisted of the understatement of Federal Assistance Listing Numbers 14.239 and 14.218 in the amounts of $364,207 and $295,000, respectively, and an overstatement of Federal Assistance Listing Number 21.027 in the amount of $66,320, for a total net understatement of $592,887. Cause: The Organization’s internal controls over the preparation and review of the SEFA were not operating effectively. Material audit adjustments were proposed during the course of the audit that lead to material changes to the SEFA. Effect or Potential Effect: Inadequate controls over the preparation of the SEFA could result in financial misstatements or potential noncompliance. Questioned Costs: None Identification as a Repeat Finding: This is a repeat finding for Assistance Listing Number 14.239. See 2022-003. Recommendation: We recommend the Organization strengthen its policies, procedures, and controls for the identification of federal awards to ensure a complete and accurate SEFA is prepared in a timely manner. Views of Responsible Officials: Management agrees with the finding and is in the process of revising internal controls to address SEFA preparation.
Federal Awards Findings and Questioned Costs Finding 2023-003 – Inaccurate SEFA - Reporting – Material Weakness Name of Federal Agency: U.S Department of Housing and Urban Development and U.S. Department of Treasury Federal Program Name: HOME Investments Partnership Program and Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 14.239 and 21.027 Federal Award Identification Number and Year: Identification number unavailable. Program years 2010, 2012, 2015, 2019, 2023. Name of Pass-through Entity (if applicable): Rhode Island Housing and Mortgage Finance Corporation and the City of Providence, Rhode Island. Criteria: In accordance with 2 CFR 200.302 (Financial Management), a grant recipient’s financial management system must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the federal statutes, regulations, and the terms and conditions of the federal award. In addition, 2 CFR 200.510 (Financial Statements), states in part that the auditee must 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 2CFR 200.502. At a minimum, the schedule must include: -All individual Federal programs by Federal agency. -For Federal awards received as a subrecipient, the name of the pass-through entity and identifying number assigned by the pass-through entity must be included. -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. -Include the total amount provided to subrecipients from each Federal program. Condition / Context: The Organization management’s review and approval process did not detect the errors that were identified during the audit procedures performed. The errors detected consisted of the understatement of Federal Assistance Listing Numbers 14.239 and 14.218 in the amounts of $364,207 and $295,000, respectively, and an overstatement of Federal Assistance Listing Number 21.027 in the amount of $66,320, for a total net understatement of $592,887. Cause: The Organization’s internal controls over the preparation and review of the SEFA were not operating effectively. Material audit adjustments were proposed during the course of the audit that lead to material changes to the SEFA. Effect or Potential Effect: Inadequate controls over the preparation of the SEFA could result in financial misstatements or potential noncompliance. Questioned Costs: None Identification as a Repeat Finding: This is a repeat finding for Assistance Listing Number 14.239. See 2022-003. Recommendation: We recommend the Organization strengthen its policies, procedures, and controls for the identification of federal awards to ensure a complete and accurate SEFA is prepared in a timely manner. Views of Responsible Officials: Management agrees with the finding and is in the process of revising internal controls to address SEFA preparation.