Finding 1160312 (2023-002)

Material Weakness Repeat Finding
Requirement
M
Questioned Costs
-
Year
2023
Accepted
2025-10-10
Audit: 370698
Organization: Trailhead Institute (CO)

AI Summary

  • Core Issue: Significant deficiencies in internal controls over subrecipient monitoring were identified, particularly in documentation and compliance checks.
  • Impacted Requirements: Failure to adhere to 2 CFR 200.331 and 200.332 regarding subrecipient evaluations, risk assessments, and monitoring obligations.
  • Recommended Follow-Up: Establish a robust process for documenting compliance checks and monitoring activities to ensure adherence to federal regulations.

Finding Text

2023-002 Subrecipient Monitoring Public Health Training Centers Program – Assistance Listing No. 93.516 Award Number: 1 T29HP46735‐01‐00 – Award Period: September 15, 2022 through September 14, 2025 Centers for Disease Control and Prevention Collaboration with Academia to Strengthen Public Health – Assistance Listing No. 93.967 Award Number: G2513_AG-1146 Amendment #1 – Award Period: February 1, 2023 through November 30, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Condition: During our testing of subrecipients, we noted documentation was not maintained demonstrating the Organization checked for suspension and debarment prior to contracting with subrecipients, subrecipient vs contractor determinations, evaluation of each subrecipient’s risk of noncompliance for purposes of determining the appropriate subrecipient monitoring, or obtaining/reviewing the most recent single audit reports for subrecipients to address findings related to a particular subaward. Criteria: According to 2 CFR 200.331, pass-through entities must make case-by-case determinations whether each agreement it makes for the disbursement of Federal program funds casts the party receiving the funds in the role of a subrecipient or a contractor. 2 CFR 200.332 requires every subaward agreement include certain information including the subrecipient’s unique entity identifier (see paragraph (a) for a list of all required data elements); additionally, 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 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). (d) Monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Pass-through entity monitoring of the subrecipient must include: (1) Reviewing financial and performance reports required by the pass-through entity. (2) Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. (3) Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by § 200.521. (4) The pass-through entity is responsible for resolving audit findings specifically related to the subaward and not responsible for resolving crosscutting findings. If a subrecipient has a current Single Audit report posted in the Federal Audit Clearinghouse and has not otherwise been excluded from receipt of Federal funding (e.g., has been debarred or suspended), the pass-through entity may rely on the subrecipient's cognizant audit agency or cognizant oversight agency to perform audit follow-up and make management decisions related to cross-cutting findings in accordance with section § 200.513(a)(3)(vii). Such reliance does not eliminate the responsibility of the pass-through entity to issue subawards that conform to agency and award-specific requirements, to manage risk through ongoing subaward monitoring, and to monitor the status of the findings that are specifically related to the subaward. (e) Depending upon the pass-through entity's assessment of risk posed by the subrecipient (as described in paragraph (b) of this section), the following monitoring tools may be useful for the pass-through entity to ensure proper accountability and compliance with program requirements and achievement of performance goals: (1) Providing subrecipients with training and technical assistance on program-related matters; and (2) Performing on-site reviews of the subrecipient's program operations; (3) Arranging for agreed-upon-procedures engagements as described in § 200.425. (f) Verify that every subrecipient is audited as required by Subpart F of this part when it is expected that the subrecipient's Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in § 200.501. (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. (h) Consider taking enforcement action against noncompliant subrecipients as described in § 200.339 of this part and in program regulations. 2 CFR 180.22 requires that contract awards not be made to parties listed on the government wide exclusions in the system for Award Management, which contains the names of parties debarred, suspended or otherwise excluded by agencies as well as parties declared ineligible under statutory or regulatory authority. Questioned Costs: None. Cause: The Organization did not have a process in place to ensure all required elements of subrecipient monitoring were documented and retained in their records. Effect: Inadequate monitoring procedures and records may not detect subrecipient noncompliance on a timely basis. This could result in the Organization entering into subrecipient agreements with organizations who are ineligible to receive federal funds or might otherwise not comply with federal laws and regulations. Recommendation: We recommend that management implement procedures to ensure that future subrecipient agreements are compared against all requirements in 2 CFR 200.331, 2 CFR 200.332, and 2 CFR 180.22 and that formal documentation of such considerations be maintained. Views of Responsible Officials and Planned Corrective Actions: Management agrees. See separately issued Corrective Action Plan.

Corrective Action Plan

Trailhead is establishing a new Contract and Compliance Coordinator role to oversee contract compliance processes and to ensure that Trailhead’s policy on subrecipient monitoring is followed. This role will be responsible for ensuring that compliance requirements are integrated at the outset of each grant. This role will be responsible for internal monitoring and auditing. This role will ensure that all grant kick-off meetings follow a standard procedure and include: 1) A clear understanding of federal requirements for all involved fiscal, program, and compliance staff 2) Delegated assignments to program staff for implementing and documenting: a) Suspension and debarment prior to contracting with subrecipients b) Subrecipient vs contractor determinations c) Evaluation of each subrecipient’s risk of noncompliance i) Establish the appropriate subrecipient monitoring level based on risk. This compliance role will have the authority to ensure the procedures are completed by the assigned staff. Evidence of the completed procedure must be documented and saved in a newly created contracts database. This database will be a centralized storage that will be reviewed during internal compliance checks to ensure all required steps have been completed and documented. These documents and associated grant and contract documents will be part of an official repository.

Categories

Subrecipient Monitoring Procurement, Suspension & Debarment

Other Findings in this Audit

  • 1160310 2023-001
    Material Weakness Repeat
  • 1160311 2023-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
94.006 Americorps State and National 94.006 $972,678
93.967 Centers for Disease Control and Prevention Collaboration with Academia to Strengthen Public Health $659,736
93.889 National Bioterrorism Hospital Preparedness Program $325,312
93.U01 Community Engagement Research Alliance Against Covid-19 Disparities $279,313
93.350 National Center for Advancing Translational Sciences $248,003
93.310 Trans-Nih Research Support $220,891
93.421 Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nation’s Health $209,921
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $132,544
93.516 Public Health Training Centers Program $124,424
93.840 Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders $111,958
93.800 Organized Approaches to Increase Colorectal Cancer Screening $75,396
21.019 Coronavirus Relief Fund $75,000
93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance $35,839
17.268 H-1b Job Training Grants $33,351
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $27,268
21.027 Coronavirus State and Local Fiscal Recovery Funds $26,608
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $11,061
93.566 Refugee and Entrant Assistance State/replacement Designee Administered Programs $3,926
93.397 Cancer Centers Support Grants $2,200