Finding 1156235 (2024-002)

Material Weakness Repeat Finding
Requirement
M
Questioned Costs
-
Year
2024
Accepted
2025-09-29
Audit: 368577

AI Summary

  • Core Issue: Management failed to conduct and document a risk assessment for subrecipients, impacting effective monitoring of compliance with federal requirements.
  • Impacted Requirements: Sections 200.303 and 200.332 of the Uniform Guidance require risk assessments and review of subrecipient audit reports to ensure compliance.
  • Recommended Follow-Up: Establish written internal controls for risk assessments and modify the audit report review process to document findings and conclusions regarding subrecipients.

Finding Text

Finding 2024-002 – Subrecipient MonitoringInformation of the federal program:Federal Grantor: United States Department of Health and Human ServicesPass-Through Grantor: Chicago Department of Public HealthAssistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)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).”Section 200.332 of the Uniform Guidance states that all pass-through entities must:“(b) Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as:(1) The subrecipient’s prior experience with the same or similar subawards,(2) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F Audit Requirements of this part, and the extent to which the same or similar subaward has been audited as a major program,(3) Whether the subrecipient has new personnel or new or substantially changed systems, and(4) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency).”Section 200.332 of the Uniform Guidance further states that all pass-through entities must:“(g) Consider whether the results of the subrecipient’s audits, on-site reviews, or other monitoring indicate conditions that necessitate adjustments to the pass-through entity’s own records.”Condition:Although subrecipient monitoring procedures were performed during the fiscal year, management did not perform and document a risk assessment upon entering into subaward agreements with its subrecipients in order to determine the extent of monitoring procedures that should be performed to be responsive to the assessed risk. In addition, management did not obtain the Uniform Guidance audit report from its subrecipients.Cause:Management did not have internal controls in place that required completion of the documentation evidencing review of the risk assessment of the subrecipients at the beginning of the award and monitoring of the Uniform Guidance audit reports of the subrecipients. The documentation was not completed as management considered the subrecipients to be vendors.Questioned costs:None.Context:Total federal expenditures passed through to subrecipients that required a risk assessment of and review of the Uniform Guidance audit report reported in the Schedule were $646,101, representing 60% of total ELC expenditures of $1,069,344 for the year ended December 31, 2024.Effect or potential effect:Monitoring performed over a subrecipient may not be responsive to the risk for that subrecipient. A subrecipient’s Uniform Guidance audit report could contain findings that are not properly reviewed and evaluated.Identification as a repeat finding, if applicable:The finding is not a repeat finding.Recommendation:Management should establish written internal controls and procedures related to subrecipient risk assessments in accordance with Uniform Guidance Section 200.33 2(b). In addition, Endeavor should modify the subrecipient Uniform Guidance audit report review process to include a section for Endeavor to document its review of and conclusions reached over the subrecipient’s Uniform Guidance audit report.Views of Responsible Officials:Management acknowledges the findings regarding subrecipient monitoring. The oversight occurred because a risk assessment was not conducted prior to entering into subaward agreements during the reporting period. We recognize the importance of ensuring that subrecipients comply with federal requirements, and we understand that effective monitoring is a key responsibility of the pass-through entity. Going forward, subrecipient monitoring will be integrated into all new subaward agreements to ensure adherence to federal requirements.

Corrective Action Plan

Finding 2024-002 – Subrecipient MonitoringAssistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)Management will implement the established Research procedures for subrecipient risk assessments in accordance with Uniform Guidance Section 200.332(b). Update the Research subrecipient monitoring checklist and use the subrecipient forms. This approach will be applied to all new subrecipient relationships starting in 2025 and beyond. Additionally, management will collaborate with Endeavor Health's legal, finance, and compliance teams to assess current processes and make any necessary corrections to improve the review and documentation of results going forward.Responsible Officials: Ashlee Jean Roffe, Director of Nutrition and Community Health, Community CARE

Categories

Subrecipient Monitoring

Other Findings in this Audit

  • 1156219 2024-003
    Material Weakness Repeat
  • 1156220 2024-003
    Material Weakness Repeat
  • 1156221 2024-003
    Material Weakness Repeat
  • 1156222 2024-003
    Material Weakness Repeat
  • 1156223 2024-003
    Material Weakness Repeat
  • 1156224 2024-003
    Material Weakness Repeat
  • 1156225 2024-003
    Material Weakness Repeat
  • 1156226 2024-003
    Material Weakness Repeat
  • 1156227 2024-003
    Material Weakness Repeat
  • 1156228 2024-003
    Material Weakness Repeat
  • 1156229 2024-003
    Material Weakness Repeat
  • 1156230 2024-003
    Material Weakness Repeat
  • 1156231 2024-003
    Material Weakness Repeat
  • 1156232 2024-003
    Material Weakness Repeat
  • 1156233 2024-003
    Material Weakness Repeat
  • 1156234 2024-001
    Material Weakness Repeat
  • 1156236 2024-003
    Material Weakness Repeat
  • 1156237 2024-003
    Material Weakness Repeat
  • 1156238 2024-003
    Material Weakness Repeat
  • 1156239 2024-003
    Material Weakness Repeat
  • 1156240 2024-003
    Material Weakness Repeat
  • 1156241 2024-003
    Material Weakness Repeat
  • 1156242 2024-003
    Material Weakness Repeat
  • 1156243 2024-001
    Material Weakness Repeat
  • 1156244 2024-003
    Material Weakness Repeat
  • 1156245 2024-003
    Material Weakness Repeat
  • 1156246 2024-003
    Material Weakness Repeat
  • 1156247 2024-003
    Material Weakness Repeat
  • 1156248 2024-003
    Material Weakness Repeat
  • 1156249 2024-003
    Material Weakness Repeat
  • 1156250 2024-003
    Material Weakness Repeat
  • 1156251 2024-003
    Material Weakness Repeat
  • 1156252 2024-003
    Material Weakness Repeat
  • 1156253 2024-003
    Material Weakness Repeat
  • 1156254 2024-003
    Material Weakness Repeat
  • 1156255 2024-003
    Material Weakness Repeat
  • 1156256 2024-003
    Material Weakness Repeat
  • 1156257 2024-003
    Material Weakness Repeat
  • 1156258 2024-003
    Material Weakness Repeat
  • 1156259 2024-003
    Material Weakness Repeat
  • 1156260 2024-003
    Material Weakness Repeat
  • 1156261 2024-003
    Material Weakness Repeat
  • 1156262 2024-003
    Material Weakness Repeat
  • 1156263 2024-003
    Material Weakness Repeat
  • 1156264 2024-003
    Material Weakness Repeat
  • 1156265 2024-003
    Material Weakness Repeat
  • 1156266 2024-003
    Material Weakness Repeat
  • 1156267 2024-003
    Material Weakness Repeat
  • 1156268 2024-003
    Material Weakness Repeat
  • 1156269 2024-003
    Material Weakness Repeat
  • 1156270 2024-003
    Material Weakness Repeat
  • 1156271 2024-003
    Material Weakness Repeat
  • 1156272 2024-003
    Material Weakness Repeat
  • 1156273 2024-003
    Material Weakness Repeat
  • 1156274 2024-003
    Material Weakness Repeat
  • 1156275 2024-003
    Material Weakness Repeat
  • 1156276 2024-003
    Material Weakness Repeat
  • 1156277 2024-003
    Material Weakness Repeat
  • 1156278 2024-003
    Material Weakness Repeat
  • 1156279 2024-003
    Material Weakness Repeat
  • 1156280 2024-003
    Material Weakness Repeat
  • 1156281 2024-003
    Material Weakness Repeat
  • 1156282 2024-003
    Material Weakness Repeat
  • 1156283 2024-003
    Material Weakness Repeat
  • 1156284 2024-003
    Material Weakness Repeat
  • 1156285 2024-003
    Material Weakness Repeat
  • 1156286 2024-003
    Material Weakness Repeat
  • 1156287 2024-003
    Material Weakness Repeat
  • 1156288 2024-003
    Material Weakness Repeat
  • 1156289 2024-003
    Material Weakness Repeat
  • 1156290 2024-003
    Material Weakness Repeat
  • 1156291 2024-003
    Material Weakness Repeat
  • 1156292 2024-003
    Material Weakness Repeat
  • 1156293 2024-003
    Material Weakness Repeat
  • 1156294 2024-003
    Material Weakness Repeat
  • 1156295 2024-003
    Material Weakness Repeat
  • 1156296 2024-003
    Material Weakness Repeat
  • 1156297 2024-003
    Material Weakness Repeat
  • 1156298 2024-003
    Material Weakness Repeat
  • 1156299 2024-003
    Material Weakness Repeat
  • 1156300 2024-003
    Material Weakness Repeat
  • 1156301 2024-003
    Material Weakness Repeat
  • 1156302 2024-003
    Material Weakness Repeat
  • 1156303 2024-003
    Material Weakness Repeat
  • 1156304 2024-003
    Material Weakness Repeat
  • 1156305 2024-003
    Material Weakness Repeat
  • 1156306 2024-003
    Material Weakness Repeat
  • 1156307 2024-003
    Material Weakness Repeat
  • 1156308 2024-003
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.866 Aging Research $1.16M
93.323 Covid-19 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $1.07M
93.242 Mental Health Research Grants $775,500
21.027 Covid-19 Coronavirus State and Local Fiscal Recovery Funds $582,530
93.391 Covid-19 Activities to Support State, Tribal, Local and Territorial (stlt)health Department Response to Public Health Or Healthcare Crisis $525,406
93.350 National Center for Advancing Translational Sciences $448,957
93.368 21st Century Cures Act - Precision Medicine Initiative $303,736
93.172 Human Genome Research $286,291
93.838 Lung Diseases Research $198,571
16.560 National Institute of Justice Research, Evaluation, and Development Project Grants $180,535
93.351 Research Infrastrcuture Programs $157,600
93.837 Cardiovascular Disease Research $108,016
93.994 Maternal and Child Health Services Block Grant to the States $100,083
93.268 Immunization Research, Demonstration, Public Information and Education Training and Clinical Skills Improvement Projects $92,586
93.859 Biomedical Research and Research Training $89,868
93.946 Cooperative Agreements to Support State-Based Safe Motherhood and Infant Health Initiative Programs $66,500
93.671 Family Violence Prevention and Services/domestic Violence Shelter and Supportive Seevices $66,397
93.865 Child Health and Human Development Extramural Research $61,357
14.218 Community Development Block Grants/entitlement Grants $34,846
93.395 Cancer Treatment Research $31,725
93.399 Cancer Control $26,068
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $24,024
93.226 Research on Healthcare Costs, Quality and Outcomes $22,635
93.855 Allergy, Immunology and Transplantation Research $19,234
12.420 Military Medical Research and Development $17,771
93.396 Cancer Biology Research $17,301
93.110 Maternal and Child Health Federal Consolidated Programs $16,507
93.353 Cancer Treatment Research $16,200
93.307 Minority Health and Health Disparities Research $12,526
93.397 Cancer Center Support Grants $10,797
93.889 National Bioterrorism Hospital Preparedness Program $10,000
93.839 Blood Diseases and Resources Research $7,626
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $7,192
93.935 Project Grants for Renovation Or Construction at Tertiary Perinatal Facilities $5,000
93.361 Nursing Research $4,563
93.667 Social Services Block Grant $2,346
93.394 Cancer Detetction and Diagnosis Research $356
93.310 Trans-Nih Research Support $-10,837