Finding 1158055 (2024-001)

Material Weakness Repeat Finding
Requirement
I
Questioned Costs
$1
Year
2024
Accepted
2025-09-30
Audit: 370005
Organization: St Barnabas Hospital (NY)

AI Summary

  • Core Issue: The Hospital failed to maintain necessary documentation for procurement, specifically for purchases above the micro-purchase threshold, leading to a material weakness in internal controls.
  • Impacted Requirements: Noncompliance with Section 200.303 of the Uniform Guidance regarding internal controls and Section 200.320 on procurement methods.
  • Recommended Follow-Up: Management should enhance procurement review processes, ensure proper documentation is retained, and provide staff training to comply with federal requirements.

Finding Text

Finding 2024-001 – Material Weakness regarding Procurement Identification of the Federal Program: Grantor: Department of Health and Human Services Program Name: Congressional Directives Assistance Listing No.: 93.493 Criteria or Specific Requirement: 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).” Title 2, Subtitle A, Chapter II, Part 200, Subpart D 200.320 - Procurement methods - outlines the acceptable methods of procurement. Purchases below the simple acquisition threshold, but above the micro-purchase threshold, require price and rate quotations to be obtained from an adequate number of qualified sources. Condition: The Hospital did not retain documentation of either (i) competitive bidding or (ii) consideration of circumstances for noncompetitive procurement for the installation of the equipment purchased under the grant, which was above the micro-purchase threshold. Section III – Federal Award Findings and Questioned Costs (continued) Cause: The Hospital’s control framework did not verify applicable procurement requirements were documented and retained prior to entering a procurement transaction. Effect or Potential Effect: The lack of effective internal controls to ensure the purchasing policy in place is followed and appropriate contemporaneous documentation is retained could result in noncompliance with procurement requirements. Questioned Costs: As there was no documentation to evidence either (i) competitive bidding occurred or (ii) consideration of circumstances for noncompetitive procurement occurred at the time of procurement, the known questioned costs are $336,160. However, as this cost for the installation of the equipment was included within the budget submitted as part of the grant application, this cost for the installation of the equipment was an allowable cost under the grant agreement. Context: During the testing of the two purchases above the micro-purchase threshold, one purchase did not have adequate documentation retained at the time of procurement outlining that competitive bidding occurred, or there were circumstances evident that would allow for noncompetitive procurement. Recommendation: Management should enhance their process for reviewing purchases made using federal funds to verify that appropriate procurement requirements are being performed prior to entering into a transaction and that adequate contemporaneous documentation is retained to evidence that such procurement requirements were satisfied. Views of Responsible Officials: Management acknowledges the finding related to procurement documentation for the installation of equipment purchased under the grant. We recognize the importance of maintaining effective internal controls to ensure compliance with procurement requirements under the Uniform Guidance. The hospital has reviewed the circumstances surrounding this transaction and agrees that documentation supporting either (i) the competitive bidding process or (ii) the justification for noncompetitive procurement was not adequately retained. While the cost was included in the approved budget and was an allowable expense under the grant agreement, we understand that the absence of contemporaneous documentation represents a material weakness in our internal control framework. Subsequent to the procurement in question, the Hospital solicited and obtained an additional bid from another qualified source to validate that the original vendor’s pricing was reasonable and consistent with market expectations. Although this does not substitute for obtaining bids prior to procurement, it provides assurance that the transaction was consistent with the principles of fair and open competition. Management has prepared a Corrective Action Plan to strengthen procurement controls, improve documentation retention, and provide staff training to ensure future compliance with Uniform Guidance requirements.

Corrective Action Plan

Finding 2024-001 Material Weakness regarding Procurement Information on the federal program: Grantor: Department of Health and Human Services Program Name: Congressional Directives Assistance Listing No.: 93.493 Views of responsible officials and planned corrective actions: Management acknowledges the finding related to procurement documentation for the installation of equipment purchased under the grant. We recognize the importance of maintaining effective internal controls to ensure compliance with procurement requirements under the Uniform Guidance. The hospital has reviewed the circumstances surrounding this transaction and agrees that documentation supporting either (i) the competitive bidding process or (ii) the justification for noncompetitive procurement was not adequately retained. While the cost was included in the approved budget and was an allowable expense under the grant agreement, we understand that the absence of contemporaneous documentation represents a material weakness in our internal control framework. Subsequent to the procurement in question, the Hospital solicited and obtained an additional bid from another qualified source to validate that the original vendor’s pricing was reasonable and consistent with market expectations. Although this does not substitute for obtaining bids prior to procurement, it provides assurance that the transaction was consistent with the principles of fair and open competition. Management has prepared a Corrective Action Plan to strengthen procurement controls, improve documentation retention, and provide staff training to ensure future compliance with Uniform Guidance requirements. Corrective Action Plan: 1. Policy Enhancement: The hospital is revising its procurement policy to more clearly define documentation requirements for purchases made with federal funds, particularly those exceeding the micro-purchase threshold. 2. Pre-Procurement Checklist: A standardized checklist will be implemented for all federally funded purchases to verify compliance with procurement methods outlined in 2 CFR §200.320, including competitive bidding or justification for noncompetitive procurement. 3. Documentation Retention: Procurement staff will be required to upload and retain all competitive quotes or sole-source justifications in the centralized procurement system prior to final approval. 4. Training: Targeted training will be provided to procurement and grants management staff to reinforce Uniform Guidance requirements and the hospital’s updated procurement policies. 5. Monitoring: The compliance department will conduct quarterly reviews of federally funded procurements above the micro-purchase threshold to ensure adherence to policies and to promptly address any gaps. Name of responsible official: William DiBitetto, Senior Vice President, Finance Projected completion date: The updated policies and procedures will be implemented within 90 days of this response. Staff training and compliance monitoring will begin immediately thereafter.

Categories

Questioned Costs Procurement, Suspension & Debarment

Programs in Audit

ALN Program Name Expenditures
14.128 Mortgage Insurance Hospitals $15.44M
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $8.80M
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $8.39M
93.493 Congressional Directives $1.21M
93.940 Hiv Prevention Activities Health Department Based $226,059
93.924 Ryan White Hiv/aids Dental Reimbursement and Community Based Dental Partnership Grants $159,987
93.318 Protecting and Improving Health Globally: Building and Strengthening Public Health Impact, Systems, Capacity and Security $58,360
93.994 Maternal and Child Health Services Block Grant to the States $50,000
93.889 National Bioterrorism Hospital Preparedness Program $6,831