Finding 1156243 (2024-001)

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

AI Summary

  • Core Issue: Expenditures for COVID-19 programs were overstated by $347,352 and $164,120 due to misclassification in the general ledger.
  • Impacted Requirements: Internal controls over federal award reporting were inadequate, violating Section 200.303 of the Uniform Guidance.
  • Recommended Follow-Up: Management should enhance internal controls and communication to ensure accurate reporting on the Schedule of Expenditures of Federal Awards (SEFA).

Finding Text

Finding 2024-001 – ReportingInformation of the federal program:Federal Grantor: Department of Health and Human Services (HHS)Assistance Listing No.: 93.391, COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare CrisisPass-Through Grantor: Chicago Department of Public HealthFederal Grantor: Department of Health and Human Services (HHS)Assistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for Infectious DiseasesPass-Through Grantor: Chicago Department of Public HealthCriteria 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 expenditures related to the COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis and the COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases were overstated by $347,352 and $164,120, respectively, 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.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:Endeavor reported expenditures of $872,758 on the preliminary SEFA, but on the final SEFA reported $525,406 related to the COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Endeavor reported expenditures of $1,233,464 on the preliminary SEFA, but on the final SEFA reported $1,069,344 related to the COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases.Identification as a repeat finding, if applicable:This is a repeat finding of 2023-001.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:Management acknowledges the findings related to SEFA reporting. The issue arose from miscommunication in determining which expenditures should be reported for the programs in question. We recognize the importance of accurate and complete reporting. We will enhance our review and communication processes to ensure clarity between program managers and the finance team when identifying reportable expenditures. We have already taken steps to address this issue by:• Creating a new policy and procedure for SEFA reporting and establishing clear guidance and documentation for expenses that should be included in the SEFA.• Implementing an expanded review process to ensure accuracy prior to submission.

Corrective Action Plan

Finding 2024-001 – ReportingAssistance Listing No.: 93.391, COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis Assistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for InfectiousDiseasesManagement will distribute the updated SEFA reporting policy and procedure, outlining the required reporting requirements and timelines. A SEFA preparation checklist will be implemented to ensure that all submissions are accurate and complete. At the end of the year, Finance and Grants Management will collaborate to review all grant activities to ensure proper inclusion in the SEFA.Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

Categories

Reporting

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
  • 1156235 2024-002
    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
  • 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