Finding 481435 (2023-001)

Significant Deficiency
Requirement
M
Questioned Costs
-
Year
2023
Accepted
2024-08-19
Audit: 317453
Organization: Vail Health Services (CO)

AI Summary

  • Core Issue: Subrecipient agreements lack required information and documentation, violating federal regulations.
  • Impacted Requirements: Non-compliance with 2 CFR 200.332(a) and (b), and 2 CFR 180.22 regarding subrecipient monitoring and risk assessment.
  • Recommended Follow-Up: Management should enhance procedures to ensure all agreements meet federal requirements and maintain proper documentation.

Finding Text

Finding 2023-001 – Significant Deficiency in Internal Control - Subrecipient Monitoring Federal Program: Block Grants for Community Mental Health Services Assistance Listing Number: 93.958 Federal Agency: U.S. Dept of Health and Human Services Passed-Through Agency: Colorado Department of Health Services Behavioral Health Division Award Number: 23 IBEH 175467 / 24 IBEH 184610 / 24 IBEH 187913 Award Year: 2023 and 2024 Compliance Requirement: Subrecipient Monitoring Questioned Costs: Not determinable Criteria: 2 CFR 200.332(a) requires that every subaward agreement includes certain information, including 1) subrecipient's unique entity identifier; 2) name of federal awarding agency; 3) assistance listing number and title; 4) identification of whether the award is R&D; and 5) indirect cost rate for the federal award (including if the de minimis rate is charged). 2 CFR 200.332(b) requires an evaluation of the subrecipient's risk of noncompliance with federal statutes, regulations and the terms and conditions of subawards as part of subrecipient monitoring and identifies specific considerations to be made during this process. 2 CFR 180.22 requires that contract awards not be made to parties listed on the government wide exclusions in the System for Award Management, which contains the names of parties debarred, suspended or otherwise excluded by agencies as well as parties declared ineligible under statutory or regulatory authority. Condition and Context: Subrecipient agreements entered into did not contain all required components as stipulated in 2 CFR 200.332(a). While the organization did have policies and procedures to evaluate its subrecipients, not all considerations noted in 2 CFR 200.332(b) are included in the policies. Furthermore, formal documentation was not maintained of specific considerations to the subrecipients that the Organization ultimately contracted with. Formal documentation was also not maintained related to verification that the subrecipients were not on the government wide exclusions list. Effect: Subrecipient agreements are missing certain data points that are required by the federal government. This could impact the subrecipients in their reporting. Lack of proper subrecipient monitoring, including the risk assessment component and verification of suspension/debarred status could result in the Organization entering into subrecipient agreements with organizations that will not comply with federal laws and regulations. Cause: The omitted components of the agreements, including lack of formal documentation of the risk assessment and verification that subrecipients were not on the federal governmentwide exclusions list were not detected by the Organization’s internal control process. Recommendation: We recommend that management implement procedures to ensure that future subrecipient agreements are compared against all requirements in 2 CFR 200.332(a), 2 CFR 200.332(b) and 2 CFR 180.22 and that formal documentation of such considerations be maintained. Planned Corrective Actions and View of Responsible Officials: Management agrees with the finding and is in the process of updating policies and procedures to be in compliance with the requirements of 2 CFR 200.332(a), 2 CFR 200.332(b) and 2 CFR 180.22.

Corrective Action Plan

The Grant Accounting Analyst and Director of Operations will ensure that every subaward agreement is clearly identified to the subrecipient and the following information will be included in our subaward agreements. • Federal Award Identification • Name of the Federal and awarding agency and contact information. • Subrecipient Name (which must match the name associated with its unique entity identifier). • Subrecipient's Unique Identifier • Federal Award Identification Number • Federal Award Date • Subaward Period of Performance • Subaward Budget Start and End Date • Amount of Federal funds obligated by this action by the Vail Health to the subrecipient. • Total amount of Federal funds obligated to the subrecipient by the Vail Health.The Grant Accounting Analyst and Director of Operations will monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statues, regulations and the terms and conditions of the subaward and that the subaward performance goals are achieved. Vail Health's monitoring of the subrecipient will include: 1. Reviewing financial and program performance reports of the subrecipient. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on any deficiencies pertaining to the subaward agreement. 3. An audit certification letter will be sent out to sub•recipients confirming their eligibility for Single Audit. Sub recipients will certify if they are eligible or not. Single Audits reports will be requested from sub-recipients receiving over $750,000 in federal funds. 4. If a sub-recipient has an audit finding, a copy of their corrective action plan will be requested by Vail Health. The Grant Accounting Analyst will complete an evaluation for risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring. This evaluation will include. • Assessing subrecipient's prior experience with Federal awards or subawards • The results of previous audits including whether the subrecipient receives a single audit in accordance with the Federal regulations. • Whether the subrecipient has new personnel or new or substantially changed systems. • The number and dollar amount of Federal awards received by the subrecipient. Depending upon assessment of risk posed by the subrecipient, the following monitoring tools will be used to ensure proper accountability and compliance with the program requirements and achievement of performance goals. • Providing subrecipients with training and technical assistance on program- related matters Performing on-site reviews of the program operations The Grant Accounting Analyst will take attend grant compliance training to acquire more knowledge on Uniform Guidance. Vail Health Sub-Recipient Monitoring policies will be updated accordingly.

Categories

Subrecipient Monitoring Procurement, Suspension & Debarment

Other Findings in this Audit

  • 1057877 2023-001
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $4.05M
93.498 Provider Relief Fund $3.38M
93.958 Block Grants for Community Mental Health Services $1.16M
21.027 Coronavirus State and Local Fiscal Recovery Funds $313,012
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $88,479