Finding 1166942 (2023-016)

Material Weakness Repeat Finding
Requirement
M
Questioned Costs
-
Year
2023
Accepted
2025-12-29
Audit: 377993
Organization: State of Kosrae (FM)

AI Summary

  • Core Issue: All four subrecipients tested failed to meet compliance requirements, leading to questioned costs of $639,897.
  • Impacted Requirements: Key monitoring and risk assessment processes were not conducted, including failure to identify subawards and ensure compliance with federal regulations.
  • Recommended Follow-Up: Implement necessary monitoring activities, conduct risk assessments, and ensure all subrecipient agreements include required information to prevent future compliance issues.

Finding Text

Federal Agency: U.S. Department of Health and Human Services AL Program: 93.959 Block Grants for Prevention and Treatment of Substance Abuse Federal Award No.: 1B08TI084652-01; 6B08TI084652-01M001; 6B08TI084652-01M002; 1B08TI083457-01; 6B08TI083457-01M001; 6B08TI083457-01M002; 6B08TI083457-01M003; and 6B08TI083457-01M004 Area: Subrecipient Monitoring Questioned Costs: $639,897 Criteria: In accordance with 45 CFR § 75.352, pass-through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass-through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (1) Federal Award Identification; (2) All requirements imposed by the pass-through entity on the subrecipient so that the Federal award is used in accordance with Federal statutes, regulations and the terms and conditions of the Federal award; (3) Any additional requirements that the pass-through entity imposes on the subrecipient in order for the pass-through entity to meet its own responsibility to the U.S. Department of Health and Human Services (HHS) awarding agency including identification of any required financial and performance reports; (4) An approved federally recognized indirect cost rate negotiated between the subrecipient and the Federal Government or, if no such rate exists, either a rate negotiated between the pass-through entity and the subrecipient (in compliance with this part), or a de minimis indirect cost rate as defined in § 75.414(f); (5) A requirement that the subrecipient permit the pass-through entity and auditors to have access to the subrecipient's records and financial statements as necessary for the pass-through entity to meet the requirements of this part; and (6) Appropriate terms and conditions concerning closeout of the subaward. 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, 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 HHS awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a HHS awarding agency). c. Consider imposing specific subaward conditions upon a subrecipient if appropriate as described in § 75.207. 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 other means. (3) Issuing a management decision for audit findings pertaining to the Federal award provided to the subrecipient from the pass-through entity as required by § 75.521. 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 § 75.425. 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 § 75.501. 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 § 75.371 and in program regulations. Condition: 1. Of four subrecipients tested, aggregating $639,897 of a total population of $639,897, the following were noted for the four (or 100%) subawards that were made during FY2023: a. Risk assessments were not performed to evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward; b. Subrecipient agreements were not provided to substantiate that every subaward is clearly identified to the subrecipient as a subaward and includes the required information at the time of the subaward; c. Monitoring activities were not performed 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; and d. Verification that subrecipient required to be audited is audited as required by Subpart F were not performed. Total FY2023 subrecipient expenditures for all four subrecipients amounted to $639,897, for which the amount is questioned. 2. Of twelve (100%) subrecipient expenditures tested, aggregating $125,061 of a total population of $639,897, no evidence was provided to substantiate that payments, made by subrecipients to vendors, were done prior to the date FSM National Government made reimbursements to the subrecipient. In addition, reimbursement payments made to the subrecipients were not provided.. No questioned costs are presented as amounts are questioned at Condition 1. Cause: The FSM National Government does not have approved/adopted written subrecipient monitoring policies and procedures. In addition, the FSM National Government failed to enforce compliance with subrecipient monitoring requirements and lacks monitoring controls over the following: 1. Risk assessments and monitoring activities of a subrecipient to evaluate each subrecipient’s risk of noncompliance and to ensure that each subrecipient complies with Federal statutes, regulations, and the terms and conditions of the subaward; and 2. Adequate documentation and systematic filing of relevant documentation supporting program costs. Effect: The FSM National Government is in noncompliance with applicable subrecipient monitoring requirements and questioned costs of $639,897 result for Condition 1. Recommendation: We recommend the FSM National Government establish an approved/adopted written subrecipient monitoring policies and procedures. In addition, the FSM National Government should implement monitoring internal control procedures over the following: 1. 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 45 CFR § 75.352; 2. Monitoring activities of a subrecipient to ensure that the subrecipient complies with Federal statutes, regulations, and the terms and conditions of the subaward; 3. Verification that subrecipients are audited as required by subpart F; and 4. Adequate documentation and systematic filing of relevant documentation to support program costs. Views of Responsible Officials: Management disagrees with the finding. Refer to FSM NG’s Views of Responsible Officials for their detailed response. Auditor Response: The audit conducted is at the FSM National Government level and not at the subrecipients level. Accordingly, as the pass-though entity, the FSM National Government must maintain adequate documentation of the required monitoring activities of its subrecipient. Further, in accordance with 2 CFR 200.1, questioned cost means an amount, expended or received from a Federal award, that in the auditor's judgment: (i) is noncompliant or suspected noncompliant with Federal statutes, regulations, or the terms and conditions of the Federal award; (ii) at the time of the audit, lacked adequate documentation to support compliance; or (iii) appeared unreasonable and did not reflect the actions a prudent person would take in the circumstances. Accordingly, as the FSM National Government was in noncompliance with the applicable subrecipient monitoring requirements and lacked adequate documentation to support compliance, questioned costs are retained.

Corrective Action Plan

• Implement procedural reviews and standardized templates to enhance subrecipient oversight, monitoring, and documentation. • Note: Questioned costs unwarranted as no tests conducted on state-level expenditures. 9/30/2026 Mr. Marcus Samo, Secretary of FSMNG Health Email: marcus.samu@fsmhealth.gov.fm

Categories

Subrecipient Monitoring

Other Findings in this Audit

  • 1166850 2023-006
    Material Weakness Repeat
  • 1166851 2023-007
    Material Weakness Repeat
  • 1166852 2023-008
    Material Weakness Repeat
  • 1166853 2023-009
    Material Weakness Repeat
  • 1166854 2023-010
    Material Weakness Repeat
  • 1166855 2023-011
    Material Weakness Repeat
  • 1166856 2023-006
    Material Weakness Repeat
  • 1166857 2023-007
    Material Weakness Repeat
  • 1166858 2023-008
    Material Weakness Repeat
  • 1166859 2023-009
    Material Weakness Repeat
  • 1166860 2023-010
    Material Weakness Repeat
  • 1166861 2023-011
    Material Weakness Repeat
  • 1166862 2023-006
    Material Weakness Repeat
  • 1166863 2023-007
    Material Weakness Repeat
  • 1166864 2023-008
    Material Weakness Repeat
  • 1166865 2023-009
    Material Weakness Repeat
  • 1166866 2023-010
    Material Weakness Repeat
  • 1166867 2023-011
    Material Weakness Repeat
  • 1166868 2023-006
    Material Weakness Repeat
  • 1166869 2023-007
    Material Weakness Repeat
  • 1166870 2023-008
    Material Weakness Repeat
  • 1166871 2023-009
    Material Weakness Repeat
  • 1166872 2023-010
    Material Weakness Repeat
  • 1166873 2023-011
    Material Weakness Repeat
  • 1166874 2023-006
    Material Weakness Repeat
  • 1166875 2023-007
    Material Weakness Repeat
  • 1166876 2023-008
    Material Weakness Repeat
  • 1166877 2023-009
    Material Weakness Repeat
  • 1166878 2023-010
    Material Weakness Repeat
  • 1166879 2023-011
    Material Weakness Repeat
  • 1166880 2023-006
    Material Weakness Repeat
  • 1166881 2023-007
    Material Weakness Repeat
  • 1166882 2023-008
    Material Weakness Repeat
  • 1166883 2023-009
    Material Weakness Repeat
  • 1166884 2023-010
    Material Weakness Repeat
  • 1166885 2023-011
    Material Weakness Repeat
  • 1166886 2023-006
    Material Weakness Repeat
  • 1166887 2023-007
    Material Weakness Repeat
  • 1166888 2023-008
    Material Weakness Repeat
  • 1166889 2023-009
    Material Weakness Repeat
  • 1166890 2023-010
    Material Weakness Repeat
  • 1166891 2023-011
    Material Weakness Repeat
  • 1166892 2023-006
    Material Weakness Repeat
  • 1166893 2023-007
    Material Weakness Repeat
  • 1166894 2023-008
    Material Weakness Repeat
  • 1166895 2023-009
    Material Weakness Repeat
  • 1166896 2023-010
    Material Weakness Repeat
  • 1166897 2023-011
    Material Weakness Repeat
  • 1166898 2023-006
    Material Weakness Repeat
  • 1166899 2023-007
    Material Weakness Repeat
  • 1166900 2023-008
    Material Weakness Repeat
  • 1166901 2023-009
    Material Weakness Repeat
  • 1166902 2023-010
    Material Weakness Repeat
  • 1166903 2023-011
    Material Weakness Repeat
  • 1166904 2023-006
    Material Weakness Repeat
  • 1166905 2023-007
    Material Weakness Repeat
  • 1166906 2023-008
    Material Weakness Repeat
  • 1166907 2023-009
    Material Weakness Repeat
  • 1166908 2023-010
    Material Weakness Repeat
  • 1166909 2023-011
    Material Weakness Repeat
  • 1166910 2023-006
    Material Weakness Repeat
  • 1166911 2023-007
    Material Weakness Repeat
  • 1166912 2023-008
    Material Weakness Repeat
  • 1166913 2023-009
    Material Weakness Repeat
  • 1166914 2023-010
    Material Weakness Repeat
  • 1166915 2023-011
    Material Weakness Repeat
  • 1166916 2023-006
    Material Weakness Repeat
  • 1166917 2023-007
    Material Weakness Repeat
  • 1166918 2023-008
    Material Weakness Repeat
  • 1166919 2023-009
    Material Weakness Repeat
  • 1166920 2023-010
    Material Weakness Repeat
  • 1166921 2023-011
    Material Weakness Repeat
  • 1166922 2023-006
    Material Weakness Repeat
  • 1166923 2023-007
    Material Weakness Repeat
  • 1166924 2023-008
    Material Weakness Repeat
  • 1166925 2023-009
    Material Weakness Repeat
  • 1166926 2023-010
    Material Weakness Repeat
  • 1166927 2023-011
    Material Weakness Repeat
  • 1166928 2023-006
    Material Weakness Repeat
  • 1166929 2023-007
    Material Weakness Repeat
  • 1166930 2023-008
    Material Weakness Repeat
  • 1166931 2023-009
    Material Weakness Repeat
  • 1166932 2023-010
    Material Weakness Repeat
  • 1166933 2023-011
    Material Weakness Repeat
  • 1166934 2023-017
    Material Weakness Repeat
  • 1166935 2023-018
    Material Weakness Repeat
  • 1166936 2023-019
    Material Weakness Repeat
  • 1166937 2023-020
    Material Weakness Repeat
  • 1166938 2023-012
    Material Weakness Repeat
  • 1166939 2023-013
    Material Weakness Repeat
  • 1166940 2023-014
    Material Weakness Repeat
  • 1166941 2023-015
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
20.106 AIRPORT IMPROVEMENT PROGRAM, INFRASTRUCTURE INVESTMENT AND JOBS ACT PROGRAMS, AND COVID-19 AIRPORTS PROGRAMS $7.62M
93.323 EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ELC) $3.76M
84.027 SPECIAL EDUCATION GRANTS TO STATES $3.73M
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $2.00M
11.431 CLIMATE AND ATMOSPHERIC RESEARCH $1.91M
15.875 ECONOMIC, SOCIAL, AND POLITICAL DEVELOPMENT OF THE TERRITORIES $943,754
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $926,326
93.116 PROJECT GRANTS AND COOPERATIVE AGREEMENTS FOR TUBERCULOSIS CONTROL PROGRAMS $857,028
93.217 FAMILY PLANNING SERVICES $606,890
93.354 PUBLIC HEALTH EMERGENCY RESPONSE: COOPERATIVE AGREEMENT FOR EMERGENCY RESPONSE: PUBLIC HEALTH CRISIS RESPONSE $540,103
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $516,493
15.904 HISTORIC PRESERVATION FUND GRANTS-IN-AID $512,290
93.069 PUBLIC HEALTH EMERGENCY PREPAREDNESS $496,380
93.958 BLOCK GRANTS FOR COMMUNITY MENTAL HEALTH SERVICES $422,475
93.391 ACTIVITIES TO SUPPORT STATE, TRIBAL, LOCAL AND TERRITORIAL (STLT) HEALTH DEPARTMENT RESPONSE TO PUBLIC HEALTH OR HEALTHCARE CRISES $402,201
93.377 PREVENTION AND CONTROL OF CHRONIC DISEASE AND ASSOCIATED RISK FACTORS IN THE U.S. AFFILIATED PACIFIC ISLANDS, U.S. VIRGIN ISLANDS, AND P. R. $390,383
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $293,369
84.325 SPECIAL EDUCATION - PERSONNEL DEVELOPMENT TO IMPROVE SERVICES AND RESULTS FOR CHILDREN WITH DISABILITIES $283,747
93.251 EARLY HEARING DETECTION AND INTERVENTION $262,950
93.092 AFFORDABLE CARE ACT (ACA) PERSONAL RESPONSIBILITY EDUCATION PROGRAM $255,308
93.889 NATIONAL BIOTERRORISM HOSPITAL PREPAREDNESS PROGRAM $209,357
93.788 OPIOID STR $183,482
45.310 GRANTS TO STATES $85,009
93.110 MATERNAL AND CHILD HEALTH FEDERAL CONSOLIDATED PROGRAMS $82,927
93.104 COMPREHENSIVE COMMUNITY MENTAL HEALTH SERVICES FOR CHILDREN WITH SERIOUS EMOTIONAL DISTURBANCES (SED) $74,975
17.225 UNEMPLOYMENT INSURANCE $71,770
93.991 PREVENTIVE HEALTH AND HEALTH SERVICES BLOCK GRANT $56,709
93.336 BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM $54,763
93.917 HIV CARE FORMULA GRANTS $49,133
93.127 EMERGENCY MEDICAL SERVICES FOR CHILDREN $42,555
97.042 EMERGENCY MANAGEMENT PERFORMANCE GRANTS $34,976
10.675 URBAN AND COMMUNITY FORESTRY PROGRAM $29,673
93.060 SEXUAL RISK AVOIDANCE EDUCATION $13,930
93.967 CENTERS FOR DISEASE CONTROL AND PREVENTION COLLABORATION WITH ACADEMIA TO STRENGTHEN PUBLIC HEALTH $13,341
59.006 8(A) BUSINESS DEVELOPMENT PROGRAM $0