Finding 1229763 (2025-001)

Material Weakness Repeat Finding
Requirement
I
Questioned Costs
-
Year
2025
Accepted
2026-09-15
Audit: 410999
Organization: Inova Health System (VA)

AI Summary

  • Core Issue: The vendor list used for suspension and debarment screenings is incomplete and lacks proper documentation, increasing the risk of using ineligible vendors.
  • Impacted Requirements: Compliance with Title 2 U.S. Code of Federal Regulations, Part 200.303, which mandates effective internal controls over federal awards.
  • Recommended Follow-Up: Management should improve controls by ensuring all vendors are screened and maintain documentation of the review process for completeness and accuracy.

Finding Text

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Awards: Assistance Listing 93.145 – HIV Related Training and Technical Assistance; Assistance Listing 93.153 – Coordinated Services and Access to Research for Women, Infants, Children, and Youth; Assistance Listing 93.939 – HIV Prevention Activities Non-Governmental Organization Based Pass-Through Entity: Assistance Listing 93.145 – University of Pittsburgh (93.145); N/A; N/A Pass-Through Entity Number: Assistance Listing 93.145 – Subaward AWD00009525; N/A; N/A Award Periods: Assistance Listing 93.145 – July 1, 2024 – June 30, 2025; July 1, 2025 – June 30, 2026; Assistance Listing 93.153 – August 1, 2024 – July 31, 2025; August 1, 2025 – July 31, 2026; Assistance Listing 93.939 – April 1, 2024 – March 31, 2025; July 1, 2024 – June 30, 2025; April 1, 2025 – March 31, 2026; July 1, 2025 – June 30, 2026 Section III – Federal Award Findings and Questioned Costs (continued) 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).” Condition Management, through the use of a service provider, validates that vendors are reviewed on a monthly basis to ensure they are not suspended or debarred. There was insufficient evidence to support management’s control activities addressing completeness and accuracy of the vendor list provided to the service provider to check for suspension and debarment. Specifically, in the evaluation of the design of the control in operation during 2025, we noted the following: 1. Lack of evidence retained of management’s review of the system generated master vendor listing used as input data prior to validation for the control. 2. Lack of second-level review over manual manipulation and filtering of data in the preparation of the master vendor listing prior to screening. 3. Incomplete identification of vendors subject to federal suspension and debarment requirements. 4. Lack of evidence retained of management’s considerations around the completeness and accuracy of information used in the exercise of the control by the service provider. Cause The System did not perform a review or retain documentation to support the completeness and accuracy of the master vendor list used for suspension and debarment. Effect or potential effect The vendor list used for suspension and debarment screening may not be complete and accurate, increasing the risk that vendors or contractors subject to federal suspension and debarment are not identified before expending federal funds. Section III – Federal Award Findings and Questioned Costs (continued) Questioned costs None. Identification of a repeat finding Not a repeat finding. Context The System utilizes a third-party service provider to perform suspension and debarment screenings. Under the System's policy, all vendors providing goods or services to federally funded programs are required to be included in the suspension and debarment screening process. Given we were aware of the conditions and cause mentioned above at the time of testing, our testing included 100% of the vendors for each of the major programs. We noted control exceptions for the major programs summarized below: • Assistance Listing 93.145 – HIV–Related Training and Technical Assistance: We identified two vendors, which throughout the audit period were not subject to the System’s search of exclusion lists for suspension and debarment. Transactions under these vendors for the period under audit totalled $1,156, which is not material to the major program. A subsequent search for these vendors for the period under audit did not yield any matches, indicating these control failures did not result in a compliance exceptions. • Assistance Listing 93.153 – Coordinated Services and Access to Research for Women, Infants, Children, and Youth: No exceptions were identified. • Assistance Listing 93.939 – HIV Prevention Activities Non–Governmental Organization Based: We identified one vendor that throughout the audit period was not subject to the System’s search of exclusion lists for suspension and debarment. Transactions under this vendor for the period under audit totalled $1,500, which is not material to the major program. A subsequent search for the vendor for the period under audit did not yield any matches, indicating these control failures did not result in a compliance exception. Given the control deficiency relates to the process used to identify vendors to be included in the screening population, the deficiency impacts the control's ability to operate effectively across the major programs above that were subject to testing. Although the omitted vendors were not identified as suspended or debarred, the exceptions demonstrate that the population used for suspension and debarment screening was not complete. Recommendation Management should enhance its suspension and debarment control to ensure all vendors associated with federally funded programs are included in the screening population. Management should maintain evidence of its review of the completeness and accuracy of the vendor population provided to the third-party service provider and the results of the screening process. View of responsible officials There is no disagreement with the audit finding.

Corrective Action Plan

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: University of Pittsburgh; Not Applicable; Not Applicable Pass-Through Entity Number: AWD00009525; Not Applicable; Not Applicable Awards: Assistance Listing 93.145 – HIV Related Training and Technical Assistance; Assistance Listing 93.153 - Coordinated Services and Access to Research for Women, Infants, Children and Youth; Assistance Listing 93.939 – HIV Prevention Activities Non-Governmental Organization Based Award Periods: July 1, 2024 to June 30, 2025; July 1, 2025 to June 30, 2026; August 1, 2024 to July 31, 2025; August 1, 2025 to July 31, 2026; April 1, 2024 to March 31, 2025; July 1, 2024 to June 30, 2025; April 1, 2025 to March 31, 2026; July 1, 2025 to June 30, 2026 Type of Finding: Significant Deficiency in Internal Control Over Compliance Description: Internal control deficiency over Procurement and Suspension and Debarment Recommendation: Management should enhance its suspension and debarment control to ensure all vendors associated with federally funded programs are included in the screening population. Management should maintain evidence of its review of the completeness and accuracy of the vendor population provided to the third-party service provider and the results of the screening process. View of responsible officials: Management concurs with the finding and has implemented procedures to ensure completeness and accuracy of the approved vendor list for monthly suspension and debarment screening. Name(s) of the Contact Person(s) Responsible for Corrective Action: Lindsay Mccrory Eric Lyda Corrective Action Planned: Inova will enhance controls over the completeness, accuracy, and documentation of the vendor population subject to monthly suspension and debarment screening. Corrective actions include implementing procedures to validate the completeness of the vendor population, reconciling the population submitted for screening to source records, standardizing report generation to reduce reliance on manual processes, and strengthening documentation of control execution to ensure continued compliance with Uniform Guidance requirements. Inova will also formalize control responsibilities and provide training to support consistent execution of the screening process. Planned Completion Date for Corrective Action Planned: September 30, 2026 2026

Categories

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1229761 2025-001
    Material Weakness Repeat
  • 1229762 2025-001
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
12.750 UNIFORMED SERVICES UNIVERSITY MEDICAL RESEARCH PROJECTS $4.10M
93.918 GRANTS TO PROVIDE OUTPATIENT EARLY INTERVENTION SERVICES WITH RESPECT TO HIV DISEASE $2.56M
93.917 HIV CARE FORMULA GRANTS $2.17M
93.939 HIV PREVENTION ACTIVITIES NON-GOVERNMENTAL ORGANIZATION BASED $1.02M
93.153 COORDINATED SERVICES AND ACCESS TO RESEARCH FOR WOMEN, INFANTS, CHILDREN, AND YOUTH $585,392
20.614 NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (NHTSA) DISCRETIONARY SAFETY GRANTS AND COOPERATIVE AGREEMENTS $445,741
93.399 CANCER CONTROL $348,489
93.145 HIV-RELATED TRAINING AND TECHNICAL ASSISTANCE $285,160
16.753 CONGRESSIONALLY RECOMMENDED AWARDS $256,831
93.859 BIOMEDICAL RESEARCH AND RESEARCH TRAINING $218,351
93.767 CHILDREN'S HEALTH INSURANCE PROGRAM $159,537
93.RD Population Health Research Support $134,318
93.866 AGING RESEARCH $131,819
93.121 ORAL DISEASES AND DISORDERS RESEARCH $85,571
93.RD NHLBI/Inova Pulmonary Vascular Program $61,516
93.RD NHLBI Graft Sample and Data Collection Project $56,812
93.914 HIV EMERGENCY RELIEF PROJECT GRANTS $36,818
93.853 EXTRAMURAL RESEARCH PROGRAMS IN THE NEUROSCIENCES AND NEUROLOGICAL DISORDERS $36,247
93.279 DRUG USE AND ADDICTION RESEARCH PROGRAMS $27,861
93.838 LUNG DISEASES RESEARCH $20,625
93.RD Observational Prospective Study-The Diversification of the Pregnant Vaginal Microbiome $20,000
93.865 CHILD HEALTH AND HUMAN DEVELOPMENT EXTRAMURAL RESEARCH $9,828
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $8,839
93.088 ADVANCING SYSTEM IMPROVEMENTS FOR KEY ISSUES IN WOMEN'S HEALTH $3,756
12.420 MILITARY MEDICAL RESEARCH AND DEVELOPMENT $3,340
93.837 CARDIOVASCULAR DISEASES RESEARCH $3,232
93.RD NHLBI Graft Protocol Transition Support Services $2,494