Finding 1156714 (2024-003)

Material Weakness Repeat Finding
Requirement
AB
Questioned Costs
-
Year
2024
Accepted
2025-09-30
Audit: 369065
Organization: Advocate Aurora Health, Inc. (IL)

AI Summary

  • Core Issue: Management failed to complete effort certifications for employees working on multiple federal programs, risking unallowable payroll costs.
  • Impacted Requirements: This violates Section 200.303 and Section 200.430(g)(1)(vi) of the Uniform Guidance regarding internal controls and documentation of personnel expenses.
  • Recommended Follow-Up: Review and enhance effort certification policies to ensure timely approvals for all employees charging to federal programs.

Finding Text

Federal Agency: United States Department of Treasury ALN: 21.027 Coronavirus State and Local Fiscal Recovery Funds Award Period: 1/1/2023 to 6/30/2025 Pass-Through Grantor Pass-Through Award Number Illinois Department of Human Services FCSDX06443, FCSDX06444, FCSDX06445 Federal Agency: United States Department of Health and Human Services Assistance Listing Federal Program Name Pass-Through Grantor Pass-Through Award Number 93.889 National Bioterrorism Hospital Preparedness Program Illinois Health and Hospital Association 197137 Illinois Department of Public Health 47280007L; 47280009L; 57280007M; and 57280009M 93.958 Block Grants for Community Mental Health Services Illinois Department of Human Services 45CCB03507 and 45CDB04209 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 200.430(g)(1)(vi) of the Uniform Guidance states that the standards for documentation of personnel expense must “Support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity”. Condition: Management did not complete effort certifications for individuals working on multiple federal programs during the year. Cause: Management did not have sufficiently designed internal controls to ensure that effort certifications were completed for individuals working on multiple federal programs. Effect or potential effect: Unallowable payroll costs may be charged to the federal program. Questioned costs: None. Context: For Coronavirus State and Local Fiscal Recovery Funds, National Bioterrorism Hospital Preparedness Program, and Block Grants for Community Mental Health Service, Advocate Aurora Health did not have employees complete effort certifications when they were working on multiple federal programs. The total expenditures reported on the Schedule for Coronavirus State and Local Fiscal Recovery Funds, National Bioterrorism Hospital Preparedness Program, and Block Grants for Community Mental Health Service are $1,460,320, $952,593, and $926,262, respectively, for the year ended December 31, 2024. Payroll costs for Coronavirus State and Local Fiscal Recovery Fund, National Bioterrorism Hospital Preparedness Program, and Block Grants for Community Mental Health Service totaled $1,150,365, $94,265, and $752,385, respectively, representing 79%, 10%, and 81%, respectively of the total expenditures. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: The Organization should review its effort certification policies and procedures and implement more robust internal controls to ensure effort certifications are approved timely for all employees charging effort to the federal program. Views of responsible officials: Management agrees with the finding and will implement standardized procedures to ensure effort certifications are completed accurately and on time for all program staff.

Corrective Action Plan

Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were completed for all individuals working on multiple federal programs. Management Response: To address the identified deficiency, management is introducing standardized procedures to ensure that effort certifications are completed accurately and on time for all program staff. Program staff will receive targeted training, and a monitoring process will be implemented to support ongoing reviews. In addition, improvements to the effort tracking methodology are being considered to enhance the accuracy of employee time reporting across multiple federal grants, thereby strengthening compliance and minimizing the risk of reporting errors. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director, Venice Northe, Grants Accounting Manager and Program teams. Anticipated Completion Date: December 31, 2025.

Categories

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Other Findings in this Audit

  • 1156690 2024-001
    Material Weakness Repeat
  • 1156691 2024-001
    Material Weakness Repeat
  • 1156692 2024-002
    Material Weakness Repeat
  • 1156693 2024-002
    Material Weakness Repeat
  • 1156694 2024-002
    Material Weakness Repeat
  • 1156695 2024-002
    Material Weakness Repeat
  • 1156696 2024-002
    Material Weakness Repeat
  • 1156697 2024-002
    Material Weakness Repeat
  • 1156698 2024-003
    Material Weakness Repeat
  • 1156699 2024-003
    Material Weakness Repeat
  • 1156700 2024-003
    Material Weakness Repeat
  • 1156701 2024-003
    Material Weakness Repeat
  • 1156702 2024-003
    Material Weakness Repeat
  • 1156703 2024-003
    Material Weakness Repeat
  • 1156704 2024-004
    Material Weakness Repeat
  • 1156705 2024-004
    Material Weakness Repeat
  • 1156706 2024-003
    Material Weakness Repeat
  • 1156707 2024-003
    Material Weakness Repeat
  • 1156708 2024-003
    Material Weakness Repeat
  • 1156709 2024-003
    Material Weakness Repeat
  • 1156710 2024-003
    Material Weakness Repeat
  • 1156711 2024-003
    Material Weakness Repeat
  • 1156712 2024-003
    Material Weakness Repeat
  • 1156713 2024-003
    Material Weakness Repeat
  • 1156715 2024-005
    Material Weakness Repeat
  • 1156716 2024-005
    Material Weakness Repeat
  • 1156717 2024-005
    Material Weakness Repeat
  • 1156718 2024-005
    Material Weakness Repeat
  • 1156719 2024-005
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.399 Cancer Control $996,083
93.788 Opioid Str $833,967
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $781,999
16.575 Crime Victim Assistance $733,904
93.073 Birth Defects and Developmental Disabilities - Prevention and Surveillance $476,939
93.889 National Bioterrorism Hospital Preparedness Program $426,242
93.958 Block Grants for Community Mental Health Services $419,516
21.019 Coronavirus Relief Fund $359,651
93.866 Aging Research $329,450
84.116 Fund for the Improvement of Postsecondary Education $318,505
93.959 Block Grants for Prevention and Treatment of Substance Abuse $268,777
93.226 Research on Healthcare Costs, Quality and Outcomes $262,701
21.027 Coronavirus State and Local Fiscal Recovery Funds $242,974
16.753 Congressionally Recommended Awards $226,240
93.493 Congressional Directives $184,115
93.083 Prevention of Disease, Disability, and Death Through Immunization and Control of Respiratory and Related Diseases $181,349
93.778 Medical Assistance Program $123,305
93.350 National Center for Advancing Translational Sciences $120,845
93.307 Minority Health and Health Disparities Research $96,018
93.840 Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders $95,460
93.395 Cancer Treatment Research $91,050
16.588 Violence Against Women Formula Grants $88,183
93.242 Mental Health Research Grants $82,002
93.566 Refugee and Entrant Assistance State/replacement Designee Administered Programs $68,903
20.600 State and Community Highway Safety $65,308
93.837 Cardiovascular Diseases Research $61,010
10.136 American Rescue Plan Act of 2021 Loan Payment $60,648
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $47,812
93.497 Family Violence Prevention and Services/ Sexual Assault/rape Crisis Services and Supports $18,500
93.969 Pphf Geriatric Education Centers $17,696
10.555 National School Lunch Program $4,884
10.558 Child and Adult Care Food Program $1,372