Finding 421364 (2022-002)

Significant Deficiency
Requirement
I
Questioned Costs
-
Year
2022
Accepted
2023-09-28
Audit: 312296
Organization: Novant Health, Inc. (NC)

AI Summary

  • Core Issue: The Company is not retaining evidence of vendor suspension and debarment checks, which is a significant deficiency in compliance.
  • Impacted Requirements: Non-federal entities must verify that vendors are not suspended or debarred before entering contracts, as per federal regulations.
  • Recommended Follow-Up: Enhance controls to ensure documentation of SAM.gov checks is maintained for each vendor, such as retaining screenshots or signed checklists.

Finding Text

2022-002: Evidence of vendor suspension and debarment checks for vendors was not retained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Assistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: N/ACondition:The Company has a policy by which all new vendors are required to be checked against the SAM.gov database by the Risk Management department prior to being entered into the accounts payable system regardless of the dollar value of the transaction. Through inquiry with the Company, they indicated that while these checks are performed, evidence of the checks is not retained. Additionally, of the 179 unique vendors used during fiscal year 2022 related to the Bioterrorism Program, PwC was unable to obtain information regarding how many were new vendors and thus subject to this check. For context, however, if the Company used the federal threshold of $25k for completing the SAM.gov checks, there were 4 transactions totaling approximately $420k above this threshold.Criteria:Non-federal entities are prohibited from contracting with or making subawards under covered transactionsto parties that are suspended or debarred. When a non-federal entity enters into a covered transactionwith an entity at a lower tier, the nonfederal entity must verify that the entity, as defined in 2 CFR section180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded fromparticipating in the transaction. This verification may be accomplished by (1) checking the System forAward Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting acertification from the entity, or (3) adding a clause or condition to the covered transaction with that entity(2 CFR section 180.300).Cause:Management?s process and controls did not include the applicable requirement of retaining history or evidence of SAM.gov vendor checks for vendors utilized by the program. As such, no single individual within the Risk Management department at the Company was retaining history or evidence of this step in the Company?s procurement and vendor setup process.Effect:The Company may do business with a vendor that is suspended or debarred if timely checks are not performed.Recommendation:We recommend the Company enhance its controls and revise its procedures surrounding vendor suspension and debarment to include a requirement that evidence is appropriately maintained of SAM.gov vendor checks for each vendor (e.g. screenshots, a checklist including this procedure that is signed, etc.).Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.

Corrective Action Plan

Management?s View and Corrective Action PlanThe following is Novant Health?s response to the audit of Federal programs in accordance with the Uniform Guidance for year ending December 31, 2022.2022-002: Evidence of vendor suspension and debarment checks for vendors was not retained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Assistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: N/AManagement understands the importance of ensuring that Novant Health does not enter into covered transactions using federal funds with vendors who have been suspended or debarred, in accordance with federal regulations. As part of the process for adding new vendors, Novant Health searches the SAM.gov website to confirm that the new vendor is not included on the Exclusions list. However, evidence of such checks, while completed, was not properly maintained.Corrective Action Plan and Anticipated Completion DateNovant Health management?s corrective action plan includes:? Maintain documentation of the completed SAM.gov checks for all new vendors to verify the appropriate checks have been conducted and any discrepancies appropriately resolved prior to being entered into the accounts payable system.? For purposes of ongoing suspension and debarment compliance for all vendors (existing and new), ensure a list of vendors paid in the previous month is sent to the Compliance department on a monthly basis to be re-screened on SAM.govNovant Health will implement the above processes beginning October 1, 2023, and will continue these processes on at least a monthly basis. This process will provide two separate confirmations ? that new vendors added do not exist on the Exclusions list of the website, and that existing vendors have not been added to that list since the initial vendor check.For follow-up questions and information, please contact Scott Whitaker, Novant Health Director of Disbursements at eswhitaker@novanthealth.org.Sincerely,E. Scott WhitakerDirector of Disbursementseswhitaker@novanthealth.org

Categories

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

Other Findings in this Audit

  • 421362 2022-001
    -
  • 421363 2022-001
    -
  • 421365 2022-002
    Significant Deficiency
  • 421366 2022-002
    Significant Deficiency
  • 421367 2022-003
    Significant Deficiency
  • 421368 2022-003
    Significant Deficiency
  • 421369 2022-003
    Significant Deficiency
  • 997804 2022-001
    -
  • 997805 2022-001
    -
  • 997806 2022-002
    Significant Deficiency
  • 997807 2022-002
    Significant Deficiency
  • 997808 2022-002
    Significant Deficiency
  • 997809 2022-003
    Significant Deficiency
  • 997810 2022-003
    Significant Deficiency
  • 997811 2022-003
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.498 Provider Relief Fund $20.79M
93.461 Covid-19 Testing for the Uninsured $4.10M
32.006 Covid-19 Telehealth Program $1.12M
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $313,575
93.889 National Bioterrorism Hospital Preparedness Program $260,655
93.778 Medical Assistance Program $211,892
93.153 Coordinated Services and Access to Research for Women, Infants, Children, and Youth $131,539
93.155 Rural Health Research Centers $126,120
93.917 Hiv Care Formula Grants $111,074
93.107 Area Health Education Centers Point of Service Maintenance and Enhancement Awards $88,295
93.110 Maternal and Child Health Federal Consolidated Programs $83,324
10.557 Special Supplemental Nutrition Program for Women, Infants, and Children $41,152
93.810 Paul Coverdell National Acute Stroke Program National Center for Chronic Disease Prevention and Health Promotion $35,175
93.226 Research on Healthcare Costs, Quality and Outcomes $17,308
93.426 Improving the Health of Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke $15,661
93.080 Blood Disorder Program: Prevention, Surveillance, and Research $12,308
93.865 Child Health and Human Development Extramural Research $4,309
93.470 Alzheimer's Disease Program Initiative (adpi) $3,391
93.421 Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nations Health $2,426
93.969 Pphf Geriatric Education Centers $850