Finding 1208805 (2025-001)

Material Weakness Repeat Finding
Requirement
BN
Questioned Costs
-
Year
2025
Accepted
2026-04-24
Audit: 399667
Auditor: KPMG LLP

AI Summary

  • Core Issue: Six employees' compensation exceeded the NIH salary cap, leading to unallowable costs totaling $227,947.
  • Impacted Requirements: Compliance with NIH salary cap provisions under 2 CFR section 200.430(d)(2) was not effectively monitored.
  • Recommended Follow-Up: FTCH should enhance internal controls and monitoring processes to ensure proper application of NIH salary caps by May 31, 2026.

Finding Text

(3) Findings and Questions Costs Relating to Federal Awards Finding 2025-001 Federal Program Title - Cancer Control Assitance Listing No. - 93.399 Federal Agency - Department of Health and Human Services - Passed through Marshfield Clinic Federal Award Identification - JHKBV97FZUC5 Grant Award Period - July 1, 2024 through June 30, 2025 Compliance Requirement - Allowable costs/Cost principles, Special Tests and Provisions Criteria: Section 2 CFR section 200.430(d)(2) states allowable compensation for certain employees is subject to a ceiling in accordance with Federal statute. Per NIH Grants Policy Statement, direct salaries of individuals in exces of the rate prescribed in the governing Appropriation Act for NHI will be adjusted in accordance with the legislative salary limitation. Condition found: During our testing of employee compensation of 25 employees, we identified 6 employees compensation exceeded the NIH salary cap provisions as follows: Salaries $161,894 - Fringe benefits $45,330 - Indirect costs $20,723 - Total $227,947 Further, we noted FTCH did not have adequately effective controls in place to ensure FTCH complies with the NIH salary cap provisions. Cause: In discussing these conditions FTCH management stated that based on documentation received as a passthrough entity, they were unaware of the NIH salary cap being applicable. As a result, a control related to the application of the NHI salary cap provisions was not put in place and therefore not operating effectively. Possible Asserted Effect: Failure to adhere to NIH salary cap provisions resulted in unallowable costs being applied to the grant, including salary and associated fringe benefits and indirect costs. Questioned Costs: $227,947 Repeat Finding: A similar finding was not reported in the prior year's audit. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Recommendation: We recommend FTCH strengthen processes and develop internal controls to ensure FTCH is appropriately monitoring and aplying NHI salary caps. View of Responsible Official: The Organization concurs with this finding. We acknowledge that salary cap limitations were not applied correctly during the period under review and have implemented enhanced controls to prevent recurrence. These corrective actions include strengthened review procedures, augmented pre-submission compliance checks, and targeted traning for staff involved in grants and financial administration. These measurs will be fully in place by May 31, 2026 to ensure consistent and accurate application of NIH salary cap requirements gong forward. The Organization remains committed to strong financial stewardship and full compliance with all applicable Federal regulations and award terms.

Corrective Action Plan

Corrective Action Plan – Material Weakness & Material Noncompliance (Single Audit) Entity Name: Froedtert ThedaCare Health (FTCH) Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Finding 2025-001 – Material Noncompliance (Major Federal Program) Federal Program U.S. Department of Health and Human Services – National Institutes of Health (NIH) – Cancer Control ALN: 93.399 Finding Description The audit identified material weakness and material noncompliance with federal program requirements related to payroll, fringe benefits and indirect costs. Specifically, FTCH did not comply with NIH Salary Cap requirements, which resulted in questioned costs that were quantitatively and qualitatively material. Cause of the Finding FTCH did not apply the NIH salary cap limitations correctly during the period under review. Corrective Action Planned • The Entity will take the following corrective actions to address the material noncompliance:  Performing a comprehensive review of all FTCH grants, both under consideration and currently active, to determine whether a salary cap limitation applies. Where applicable, management will confirm that the salary cap is being consistently and accurately applied in accordance with governing requirements. Any discrepancies identified have been or will be corrected in a timely manner.  Enhancing pre-award and pre-submission compliance controls through updates to grant review procedures and compliance checklists. These updates are designed to ensure that grants subject to salary cap limitations are clearly flagged and that salary calculations are reviewed and documented prior to submission and award acceptance.  Providing targeted training for staff involved in grant administration, budgeting, payroll processing, and financial reporting to ensure consistent understanding and application of salary cap requirements and related internal control procedures.  Conducting periodic internal monitoring reviews of salary charges to federal awards to assess ongoing compliance, validate the effectiveness of internal controls, and identify potential issues before they result in noncompliance. Results of these reviews will be documented, and corrective actions implemented as appropriate. Personnel Responsible: SVP Finance Anticipated Completion Date: May 31, 2026 Status of Corrective Action Corrective action has been initiated and will be completed within the stated timeframe. Management Certification Management certifies that the corrective actions described above are accurate, appropriate, and will be implemented as represented. ____________________ Matt Partridge SVP Finance April ___, 2026

Categories

Allowable Costs / Cost Principles Special Tests & Provisions

Programs in Audit

ALN Program Name Expenditures
93.399 CANCER CONTROL $743,332
93.493 CONGRESSIONAL DIRECTIVES $429,013
93.083 PREVENTION OF DISEASE, DISABILITY, AND DEATH THROUGH IMMUNIZATION AND CONTROL OF RESPIRATORY AND RELATED DISEASES $182,544
93.912 RURAL HEALTHCARE SERVICES PROGRAMS $174,501
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $71,315
93.301 SMALL RURAL HOSPITAL IMPROVEMENT GRANT PROGRAM $64,300
93.241 STATE RURAL HOSPITAL FLEXIBILITY PROGRAM $59,665
93.426 THE NATIONAL CARDIOVASCULAR HEALTH PROGRAM $5,019