Finding 1205418 (2025-004)

Material Weakness Repeat Finding
Requirement
I
Questioned Costs
-
Year
2025
Accepted
2026-03-31

AI Summary

  • Core Issue: The Corporation lacks proper internal controls to ensure the vendor list for suspension and debarment is complete and accurate.
  • Impacted Requirements: Compliance with federal regulations on internal controls and suspension/debarment processes is at risk, potentially leading to using ineligible vendors.
  • Recommended Follow-up: Implement a system to retain documentation that verifies the completeness and accuracy of the vendor list and screening results.

Finding Text

Finding Reference: 2025-004 – I. Procurement, Suspension and Debarment Federal Program Information Federal Agencies: Department of Health and Human Services Department of Justice Awards: Assistance Listing 93.078 – Strengthening Emergency Care Delivery in the United States Healthcare System through Health Information and Promotion Assistance Listing 16.753 – Congressionally Recommended Awards Award Periods: September 30, 2023 – September 29, 2025 July 1, 2024 – September 30, 2026 Description: Evidence of controls over Suspension and Debarment Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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 C 200.214 – Suspension and debarment – Non-Federal entities are subject to the non-procurement debarment and suspension regulations that restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Condition As part of our testing over the operating effectiveness of internal controls over the Procurement, Suspension and Debarment assertion for our major programs, we noted that the Corporation did not have appropriately designed internal controls in order to retain evidence related to the completeness and accuracy of the vendor list and monthly results for suspension and debarment. The Corporation validates that vendors are reviewed on a monthly basis to ensure they are not included on the suspension and debarment list. There was no documentation retained to support the vendor list and results were complete and accurate for the monthly validation. Cause The Corporation did not retain sufficient evidence to support the completeness and accuracy of the vendor list and results for suspension and debarment. Effect or potential effect The vendor list and monthly results for suspension and debarment may not be complete and accurate and therefore, vendors used for federally funded activities may be suspended or debarred and result in noncompliance with the requirement. Questioned costs None. Identification of a repeat finding This is a repeat finding of 2024-007. Context As part of the suspension and debarment testing, we did not identify any vendors that were excluded from the vendor list, monthly results or included within the suspension and debarment list. Management retained evidence of the monthly review including their documentation of follow ups on any vendors that required further investigation. Recommendation The Corporation should retain documentation to support completeness and accuracy of the vendor list submitted for screening and the results obtained to support the screening process to ensure that no suspended or debarred vendors are utilized by the Corporation prior to entering into transactions. View of responsible officials There is no disagreement with the audit finding.

Corrective Action Plan

I. Procurement, Suspension and Debarment Evidence of controls over Suspension and Debarment Assistance Listing Assistance Listing 93.078 – Strengthening Emergency Care Delivery in the United States Healthcare System through Health Information and Promotion Assistance Listing 16.753 – Congressionally Recommended Awards Federal Agency: Department of Health and Human Services Department of Justice Recommendation: The Corporation should retain documentation to support completeness and accuracy of the vendor list submitted for screening and the results obtained to support the screening process to ensure that no suspended or debarred vendors are utilized by the Corporation prior to entering into transactions. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation will formalize the system of record and end-to-end data flow, implement monthly reconciliations to confirm the completeness of the vendor population submitted for screening, and introduce data validation checks to ensure the accuracy of key vendor information. Supporting documentation will be centrally maintained to evidence control execution, and related policies and procedures will be updated with targeted training to promote consistent and sustainable application. Collectively, these enhancements are designed to mitigate the risk of engaging with suspended or debarred vendors. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Allison Dennison, Director, Compliance Operations, Allison.Dennison@umm.edu

Categories

Procurement, Suspension & Debarment

Other Findings in this Audit

  • 1205412 2025-001
    Material Weakness Repeat
  • 1205413 2025-002
    Material Weakness Repeat
  • 1205414 2025-002
    Material Weakness Repeat
  • 1205415 2025-003
    Material Weakness Repeat
  • 1205416 2025-003
    Material Weakness Repeat
  • 1205417 2025-004
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
16.753 CONGRESSIONALLY RECOMMENDED AWARDS $290,507
93.078 STRENGTHENING EMERGENCY CARE DELIVERY IN THE UNITED STATES HEALTHCARE SYSTEM THROUGH HEALTH INFORMATION AND PROMOTION $120,218
16.320 SERVICES FOR TRAFFICKING VICTIMS $108,682
21.027 COVID-19 - CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $101,034
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $86,587
16.738 EDWARD BYRNE MEMORIAL JUSTICE ASSISTANCE GRANT PROGRAM $83,136
16.588 VIOLENCE AGAINST WOMEN FORMULA GRANTS $72,945
16.017 SEXUAL ASSAULT SERVICES FORMULA PROGRAM $47,000
16.838 COMPREHENSIVE OPIOID, STIMULANT, AND OTHER SUBSTANCES USE PROGRAM $46,275
66.466 GEOGRAPHIC PROGRAMS - CHESAPEAKE BAY PROGRAM $29,722
20.600 STATE AND COMMUNITY HIGHWAY SAFETY $24,681
93.945 Assistance Programs for Chronic Disease Prevention and Control $2,000