Finding 1156719 (2024-005)

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

AI Summary

  • Core Issue: The Organization failed to maintain proper property records and did not conduct required physical inventories for federal equipment.
  • Impacted Requirements: This violates Sections 200.303 and 200.313 of the Uniform Guidance regarding internal controls and equipment management.
  • Recommended Follow-Up: Implement stronger internal controls to ensure accurate property records and conduct physical inventories every two years.

Finding Text

Federal Agency: United States Department of Health and Human Services ALN: 93.889 National Bioterrorism Hospital Preparedness Program Pass-Through Grantor: Illinois Department of Public Health and Illinois Health and Hospital Association Pass-Through Award Number: 47280007L; 47280009L; 57280007M; 57280009M; and 197137 Award Period: 7/1/2023 to 6/30/2025 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 200.313(d)(1) and (2) states, “Regardless of whether equipment is acquired in part or its entirety under the Federal award, the recipient or subrecipient must manage equipment (including replacement equipment) utilizing procedures that meet the following requirements: (1) Property records must include a description of the property, a serial number or another identification number, the source of funding for the property (including the FAIN), the title holder, the acquisition date, the cost of the property, the percentage of the Federal agency contribution towards the original purchase, the location, use and condition of the property, and the disposition data including the date of disposal and sale price of the property. The recipient and subrecipient are responsible for maintaining and updating property records when there is a change in the status of the property. (2) A physical inventory of the property must be conducted, and the results must be reconciled with the property records at least once every two years.” Condition: The Organization did not retain property records documenting the appropriate criteria required by Section 200.313(d)(1) and (2), and did not conduct a physical inventory of property. Cause: The Organization did not have sufficiently designed internal controls to ensure that property records are retained in accordance with Section 200.313(d)(1) and (2), and to ensure that physical inventory procedures are conducted over property at least once every two years. Effect or potential effect: Federal equipment may not be maintained or disposed of in accordance with federal regulations. Questioned costs: None. Context: We tested a sample of 5 items from the equipment listing related to the federal program for the period January 1, 2024 through December 31, 2024. For all five items, there was no evidence that a physical inventory was performed in the last two years. For one item selected for testing the serial number listed on the listing did not match the serial number of the item selected. The total National Bioterrorism Hospital Preparedness Program expenditures reported on the Schedule are $952,593 for the year ended December 31, 2024. The net book value of all assets related to this federal program were $205,978. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: The Organization should implement more robust internal controls to ensure that accurate property records are maintained and physical inventory procedures over property are conducted at least once every two years. Views of responsible officials: Management agrees with the finding. Program and Fixed Asset Accounting teams will collaborate to ensure adherence to the established asset tracking and inventory management procedures. The joint effort will ensure that the subsidiary ledger is maintained, equipment acquired through federal grants is properly recorded, and physical inventories are conducted within the prescribed timelines.

Corrective Action Plan

Finding 2024-005 National Bioterrorism Hospital Preparedness Program (ALN 93.889) The Organization did not have sufficiently designed internal controls to ensure that property records are retained in accordance with Section 200.313(d)(1) and (2), and to ensure that physical inventory procedures are conducted over property at least once every two years as it pertains to the Program. Management Response: To address this deficiency, the Program and Fixed Asset Accounting teams will collaborate to ensure adherence to the established asset tracking and inventory management procedures. This joint effort will ensure that the subsidiary ledger is accurately maintained, equipment acquired through federal grants is properly recorded, and physical inventories are conducted within the prescribed biennial timelines in compliance with 2 CFR section 200.313(d). Contact Person (s) Responsible for Corrective Action: Steve Baron, Program Manager and Tony Hamric, Fixed Assets Manager. Anticipated Completion Date: December 31, 2025

Categories

Equipment & Real Property Management

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
  • 1156714 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

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