Finding 979370 (2023-005)

Significant Deficiency
Requirement
I
Questioned Costs
$1
Year
2023
Accepted
2024-06-26
Audit: 310163
Organization: Mayo Clinic (MN)

AI Summary

  • Core Issue: Internal controls over procurement were not effectively followed, with key documentation often completed after purchases were made.
  • Impacted Requirements: Violations of Uniform Guidance Sections 200.303, 200.320, and 200.214 regarding procurement justification and suspension/debarment checks.
  • Recommended Follow-Up: Strengthen the review process for procurement justification forms and ensure they are completed before any purchases are made to comply with federal requirements.

Finding Text

Procurement, Suspension and Debarment Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Federal Cluster: Research and Development (R&D) Pass-Through Entity: The University of Texas Health (93.853, NS119834) Assistance Listing Nos.: 12.420, 93.310, 93.353, 93.393, and 93.853 Award Numbers: W81XWH-15-1-0292 (12.420), OD23121 (93.310), CA246568 (93.353), CA259201 (93.393), NS119834 (93.853), NS122096 (93.853) Award Periods: Various Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “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).” Section 200.320(a)(2)(i) of the Uniform Guidance states the following regarding small purchases: “The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity.” Section 200.320(b) of the Uniform Guidance states the following regarding formal procurement methods to be followed: “When the value of the procurement for property or services under a Federal financial assistance award exceeds the simplified acquisition threshold (SAT), or a lower threshold established by a non-Federal entity, formal procurement methods are required. Formal procurement methods require following documented procedures. Formal procurement methods also require public advertising unless a non-competitive procurement can be used in accordance with § 200.319 or paragraph (c) of this section.” Section 200.214 of the Uniform Guidance states “Non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 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.” The Clinic procurement justification form for procurements more than $25,000 requires completion of the rationale for the procurement and a search of the federal government’s exclusion list to be performed and documented at the time of the procurement. On a monthly basis, Supply Chain Management performs a review of completed procurement justification forms related to procurements > $25,000 to ensure they are documented in accordance with the Clinic’s procurement, suspension and debarment policies and procedures. Condition: Internal Control For five (56%) of nine procurement transactions tested for operating effectiveness of internal controls, the procurement justification form used by the Clinic to document the history of the procurement and compliance with Uniform Guidance CFR 200.303, was not completed until after the purchase order was created and/or invoice received from the vendor. In addition, for these same five procurement transactions, the Clinic did not timely document its suspension and debarment check at the time of procurement as required by its procurement justification form. In addition, for four (44%) of nine procurement transactions tested for operating effectiveness of internal controls (two of which relate to the five cited above), the procurement justification form used by the Clinic to document the procurement transaction’s compliance with policies, procedures and the Uniform Guidance was outdated. Furthermore, the monthly review of completed procurement justification forms related to procurements > $25,000 to ensure they are documented in accordance with the Clinic’s procurement, suspension and debarment policies and procedures was not operating effectively. Compliance For one (9%) of 11 procurement transactions tested for compliance, the procurement was an add-on purchase related to a larger procurement of the same product under a prior purchase order. The prior procurement was above the simplified acquisition threshold and the Clinic’s competitive bid threshold. The Clinic did not complete a procurement justification form for the add-on purchase (which was a small purchase), and the original procurement did not have adequate support to evidence that it had been competitively bid. As such, adequate documentation did not exist for the procurement in accordance with Uniform Guidance Section 230.320(a)(2)(i) and(b). In addition, for five procurement transactions, the Clinic did not follow its suspension and debarment procedures as required by its procurement justification form. Cause: While management has internal controls in place to review procurements > $25,000 to ensure they are documented in accordance with the Clinic’s procurement, suspension and debarment policies and procedures and Uniform Guidance CFR 200.320, the review of the procurement justification form is not robust enough to identify errors and there is not a process in place to ensure the form is completed prior to the purchase. Effect or potential effect: The Clinic’s internal controls over procurement were not properly followed during the fiscal year. In addition, the Clinic did not follow the Uniform Guidance requirements related to small purchases and noncompetitive procurements. Questioned costs: $53,482, determined as the amount of the procurement expenditures included in the schedule of expenditures of federal awards for the year ended December 31, 2023, for the one procurement transaction that had inadequate support for compliance with CFR 200.320 at the time of procurement, as follows: • Assistance Listing No. 93.310, OD023121 – $53,482 Context: Internal Control We sampled nine federal procurements over $25,000 to test operating effectiveness of internal controls, totaling $962,393, from a population of 74 federal procurements over $25,000, totaling $5,400,242 and noted the following: • For seven of the 11 federal procurements tested totaling $770,093, procurement controls were not operating effectively. • For five of 11 procurement transactions tested totaling $529,273, the independent suspension and debarment check to be performed at the time of procurement was not performed until approximately two to eight months later. Compliance We sampled 11 federal procurements over $25,000 to test compliance, totaling $1,736,844, from a population of 74 federal procurements over $25,000, totaling $5,400,242 and noted the following: • For one of 11 federal procurements tested totaling $53,482, documentation retained was not adequate to support that the procurement transaction was executed in accordance with the Uniform Guidance Sections 200.320(a)(2)(i) and (b). • For five of 11 procurement transactions tested totaling $529,273, the Clinic did not follow its suspension and debarment procedures as required by its procurement justification form. Procurement-related expenditures are approximately 9% of total Federal expenditures for the R&D Cluster of $445,961,340 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is not a repeat of the finding of the prior year. Recommendation: The Clinic should ensure that all R&D awards that require procurement of goods and services follow established policies, procedures, and internal controls to comply with the Uniform Guidance procurement standards and that the procurement justification form is reviewed prior to entering into the purchase transaction. The Clinic should ensure that independent checks for suspension and debarment should be timely completed at the time of procurement in accordance with the Clinic documented policies, procedures, and internal controls. Views of responsible officials: Management will reinforce education and training to the research community and procurement teams regarding the procurement requirements, Justification of Source Selection Checklist/Form, and timely completion of the required documentation. The Clinic utilizes a third party, Visual Compliance, to execute daily supplier sanction and debarment checks for all Mayo Clinic vendors. All third party suspension and debarment match alerts are reviewed and adjudicated as needed. Going forward, the Clinic will supplement this daily review by periodically validating a sample of vendors who are not flagged with an alert by Visual Compliance.

Categories

Questioned Costs Procurement, Suspension & Debarment

Other Findings in this Audit

  • 402904 2023-002
    Material Weakness Repeat
  • 402905 2023-003
    Material Weakness
  • 402906 2023-004
    Material Weakness
  • 402907 2023-004
    Material Weakness
  • 402908 2023-005
    Significant Deficiency
  • 402909 2023-002
    Material Weakness Repeat
  • 402910 2023-004
    Material Weakness
  • 402911 2023-002
    Material Weakness Repeat
  • 402912 2023-004
    Material Weakness
  • 402913 2023-002
    Material Weakness Repeat
  • 402914 2023-004
    Material Weakness
  • 402915 2023-003
    Material Weakness
  • 402916 2023-004
    Material Weakness
  • 402917 2023-002
    Material Weakness Repeat
  • 402918 2023-004
    Material Weakness
  • 402919 2023-005
    Significant Deficiency
  • 402920 2023-002
    Material Weakness Repeat
  • 402921 2023-004
    Material Weakness
  • 402922 2023-002
    Material Weakness Repeat
  • 402923 2023-004
    Material Weakness
  • 402924 2023-002
    Material Weakness Repeat
  • 402925 2023-004
    Material Weakness
  • 402926 2023-002
    Material Weakness Repeat
  • 402927 2023-004
    Material Weakness
  • 402928 2023-005
    Significant Deficiency
  • 402929 2023-002
    Material Weakness Repeat
  • 402930 2023-003
    Material Weakness
  • 402931 2023-004
    Material Weakness
  • 402932 2023-005
    Significant Deficiency
  • 402933 2023-002
    Material Weakness Repeat
  • 402934 2023-004
    Material Weakness
  • 402935 2023-002
    Material Weakness Repeat
  • 402936 2023-004
    Material Weakness
  • 402937 2023-002
    Material Weakness Repeat
  • 402938 2023-004
    Material Weakness
  • 402939 2023-004
    Material Weakness
  • 402940 2023-002
    Material Weakness Repeat
  • 402941 2023-004
    Material Weakness
  • 402942 2023-003
    Material Weakness
  • 402943 2023-002
    Material Weakness Repeat
  • 402944 2023-004
    Material Weakness
  • 402945 2023-002
    Material Weakness Repeat
  • 402946 2023-004
    Material Weakness
  • 402947 2023-004
    Material Weakness
  • 402948 2023-004
    Material Weakness
  • 402949 2023-002
    Material Weakness Repeat
  • 402950 2023-004
    Material Weakness
  • 402951 2023-004
    Material Weakness
  • 402952 2023-002
    Material Weakness Repeat
  • 402953 2023-004
    Material Weakness
  • 402954 2023-003
    Material Weakness
  • 402955 2023-002
    Material Weakness Repeat
  • 402956 2023-004
    Material Weakness
  • 402957 2023-002
    Material Weakness Repeat
  • 402958 2023-004
    Material Weakness
  • 402959 2023-002
    Material Weakness Repeat
  • 402960 2023-004
    Material Weakness
  • 402961 2023-002
    Material Weakness Repeat
  • 402962 2023-004
    Material Weakness
  • 402963 2023-002
    Material Weakness Repeat
  • 402964 2023-004
    Material Weakness
  • 402965 2023-004
    Material Weakness
  • 402966 2023-003
    Material Weakness
  • 402967 2023-005
    Significant Deficiency
  • 402968 2023-002
    Material Weakness Repeat
  • 402969 2023-004
    Material Weakness
  • 402970 2023-002
    Material Weakness Repeat
  • 402971 2023-004
    Material Weakness
  • 402972 2023-002
    Material Weakness Repeat
  • 402973 2023-003
    Material Weakness
  • 402974 2023-004
    Material Weakness
  • 402975 2023-002
    Material Weakness Repeat
  • 402976 2023-004
    Material Weakness
  • 402977 2023-002
    Material Weakness Repeat
  • 402978 2023-004
    Material Weakness
  • 402979 2023-002
    Material Weakness Repeat
  • 402980 2023-004
    Material Weakness
  • 402981 2023-003
    Material Weakness
  • 402982 2023-004
    Material Weakness
  • 402983 2023-002
    Material Weakness Repeat
  • 402984 2023-004
    Material Weakness
  • 402985 2023-002
    Material Weakness Repeat
  • 402986 2023-004
    Material Weakness
  • 402987 2023-002
    Material Weakness Repeat
  • 402988 2023-004
    Material Weakness
  • 402989 2023-002
    Material Weakness Repeat
  • 402990 2023-004
    Material Weakness
  • 402991 2023-002
    Material Weakness Repeat
  • 402992 2023-004
    Material Weakness
  • 402993 2023-002
    Material Weakness Repeat
  • 402994 2023-004
    Material Weakness
  • 402995 2023-002
    Material Weakness Repeat
  • 402996 2023-004
    Material Weakness
  • 402997 2023-004
    Material Weakness
  • 402998 2023-002
    Material Weakness Repeat
  • 402999 2023-004
    Material Weakness
  • 403000 2023-002
    Material Weakness Repeat
  • 403001 2023-004
    Material Weakness
  • 403002 2023-004
    Material Weakness
  • 403003 2023-002
    Material Weakness Repeat
  • 403004 2023-004
    Material Weakness
  • 403005 2023-002
    Material Weakness Repeat
  • 403006 2023-004
    Material Weakness
  • 403007 2023-002
    Material Weakness Repeat
  • 403008 2023-004
    Material Weakness
  • 403009 2023-004
    Material Weakness
  • 403010 2023-002
    Material Weakness Repeat
  • 403011 2023-004
    Material Weakness
  • 403012 2023-004
    Material Weakness
  • 403013 2023-005
    Significant Deficiency
  • 403014 2023-004
    Material Weakness
  • 403015 2023-004
    Material Weakness
  • 403016 2023-002
    Material Weakness Repeat
  • 403017 2023-004
    Material Weakness
  • 403018 2023-002
    Material Weakness Repeat
  • 403019 2023-004
    Material Weakness
  • 403020 2023-001
    Significant Deficiency
  • 979346 2023-002
    Material Weakness Repeat
  • 979347 2023-003
    Material Weakness
  • 979348 2023-004
    Material Weakness
  • 979349 2023-004
    Material Weakness
  • 979350 2023-005
    Significant Deficiency
  • 979351 2023-002
    Material Weakness Repeat
  • 979352 2023-004
    Material Weakness
  • 979353 2023-002
    Material Weakness Repeat
  • 979354 2023-004
    Material Weakness
  • 979355 2023-002
    Material Weakness Repeat
  • 979356 2023-004
    Material Weakness
  • 979357 2023-003
    Material Weakness
  • 979358 2023-004
    Material Weakness
  • 979359 2023-002
    Material Weakness Repeat
  • 979360 2023-004
    Material Weakness
  • 979361 2023-005
    Significant Deficiency
  • 979362 2023-002
    Material Weakness Repeat
  • 979363 2023-004
    Material Weakness
  • 979364 2023-002
    Material Weakness Repeat
  • 979365 2023-004
    Material Weakness
  • 979366 2023-002
    Material Weakness Repeat
  • 979367 2023-004
    Material Weakness
  • 979368 2023-002
    Material Weakness Repeat
  • 979369 2023-004
    Material Weakness
  • 979371 2023-002
    Material Weakness Repeat
  • 979372 2023-003
    Material Weakness
  • 979373 2023-004
    Material Weakness
  • 979374 2023-005
    Significant Deficiency
  • 979375 2023-002
    Material Weakness Repeat
  • 979376 2023-004
    Material Weakness
  • 979377 2023-002
    Material Weakness Repeat
  • 979378 2023-004
    Material Weakness
  • 979379 2023-002
    Material Weakness Repeat
  • 979380 2023-004
    Material Weakness
  • 979381 2023-004
    Material Weakness
  • 979382 2023-002
    Material Weakness Repeat
  • 979383 2023-004
    Material Weakness
  • 979384 2023-003
    Material Weakness
  • 979385 2023-002
    Material Weakness Repeat
  • 979386 2023-004
    Material Weakness
  • 979387 2023-002
    Material Weakness Repeat
  • 979388 2023-004
    Material Weakness
  • 979389 2023-004
    Material Weakness
  • 979390 2023-004
    Material Weakness
  • 979391 2023-002
    Material Weakness Repeat
  • 979392 2023-004
    Material Weakness
  • 979393 2023-004
    Material Weakness
  • 979394 2023-002
    Material Weakness Repeat
  • 979395 2023-004
    Material Weakness
  • 979396 2023-003
    Material Weakness
  • 979397 2023-002
    Material Weakness Repeat
  • 979398 2023-004
    Material Weakness
  • 979399 2023-002
    Material Weakness Repeat
  • 979400 2023-004
    Material Weakness
  • 979401 2023-002
    Material Weakness Repeat
  • 979402 2023-004
    Material Weakness
  • 979403 2023-002
    Material Weakness Repeat
  • 979404 2023-004
    Material Weakness
  • 979405 2023-002
    Material Weakness Repeat
  • 979406 2023-004
    Material Weakness
  • 979407 2023-004
    Material Weakness
  • 979408 2023-003
    Material Weakness
  • 979409 2023-005
    Significant Deficiency
  • 979410 2023-002
    Material Weakness Repeat
  • 979411 2023-004
    Material Weakness
  • 979412 2023-002
    Material Weakness Repeat
  • 979413 2023-004
    Material Weakness
  • 979414 2023-002
    Material Weakness Repeat
  • 979415 2023-003
    Material Weakness
  • 979416 2023-004
    Material Weakness
  • 979417 2023-002
    Material Weakness Repeat
  • 979418 2023-004
    Material Weakness
  • 979419 2023-002
    Material Weakness Repeat
  • 979420 2023-004
    Material Weakness
  • 979421 2023-002
    Material Weakness Repeat
  • 979422 2023-004
    Material Weakness
  • 979423 2023-003
    Material Weakness
  • 979424 2023-004
    Material Weakness
  • 979425 2023-002
    Material Weakness Repeat
  • 979426 2023-004
    Material Weakness
  • 979427 2023-002
    Material Weakness Repeat
  • 979428 2023-004
    Material Weakness
  • 979429 2023-002
    Material Weakness Repeat
  • 979430 2023-004
    Material Weakness
  • 979431 2023-002
    Material Weakness Repeat
  • 979432 2023-004
    Material Weakness
  • 979433 2023-002
    Material Weakness Repeat
  • 979434 2023-004
    Material Weakness
  • 979435 2023-002
    Material Weakness Repeat
  • 979436 2023-004
    Material Weakness
  • 979437 2023-002
    Material Weakness Repeat
  • 979438 2023-004
    Material Weakness
  • 979439 2023-004
    Material Weakness
  • 979440 2023-002
    Material Weakness Repeat
  • 979441 2023-004
    Material Weakness
  • 979442 2023-002
    Material Weakness Repeat
  • 979443 2023-004
    Material Weakness
  • 979444 2023-004
    Material Weakness
  • 979445 2023-002
    Material Weakness Repeat
  • 979446 2023-004
    Material Weakness
  • 979447 2023-002
    Material Weakness Repeat
  • 979448 2023-004
    Material Weakness
  • 979449 2023-002
    Material Weakness Repeat
  • 979450 2023-004
    Material Weakness
  • 979451 2023-004
    Material Weakness
  • 979452 2023-002
    Material Weakness Repeat
  • 979453 2023-004
    Material Weakness
  • 979454 2023-004
    Material Weakness
  • 979455 2023-005
    Significant Deficiency
  • 979456 2023-004
    Material Weakness
  • 979457 2023-004
    Material Weakness
  • 979458 2023-002
    Material Weakness Repeat
  • 979459 2023-004
    Material Weakness
  • 979460 2023-002
    Material Weakness Repeat
  • 979461 2023-004
    Material Weakness
  • 979462 2023-001
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
84.268 Federal Direct Student Loans $18.06M
93.350 National Center for Advancing Translational Sciences $833,697
93.068 Chronic Diseases: Research, Control, and Prevention $752,871
93.947 Tuberculosis Demonstration, Research, Public and Professional Education $673,001
21.027 Covid-19 Coronavirus State and Local Fiscal Recovery Funds $630,889
93.840 Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders $596,879
93.397 Cancer Centers Support Grants $372,428
14.157 Supportive Housing for the Elderly $302,998
93.273 Alcohol Research Programs $280,983
93.RD Contract $266,975
93.839 Blood Diseases and Resources Research $257,935
93.361 Nursing Research $234,881
93.U01 Military Health Professions Scholarships $219,135
93.351 Research Infrastructure Programs $210,619
47.070 Computer and Information Science and Engineering $198,119
93.917 Hiv Care Formula Grants $181,596
12.750 Uniformed Services University Medical Research Projects $176,257
93.242 Mental Health Research Grants $161,880
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $156,484
12.RD Contract $133,212
93.837 Cardiovascular Diseases Research $126,119
93.268 Immunization Cooperative Agreements $114,649
93.433 Acl National Institute on Disability, Independent Living, and Rehabilitation Research $108,398
93.889 National Bioterrorism Hospital Preparedness Program $102,051
12.910 Research and Technology Development $97,769
93.083 Prevention of Disease, Disability, and Death Through Immunization and Control of Respiratory and Related Diseases $97,084
16.575 Crime Victim Assistance $93,603
14.871 Section 8 Housing Choice Vouchers $81,532
93.172 Human Genome Research $80,488
93.859 Biomedical Research and Research Training $72,531
93.113 Environmental Health $64,479
93.121 Oral Diseases and Disorders Research $63,259
16.560 National Institute of Justice Research, Evaluation, and Development Project Grants $61,857
93.310 Trans-Nih Research Support $57,772
93.103 Food and Drug Administration_research $56,936
47.074 Biological Sciences $54,543
93.318 Protecting and Improving Health Globally: Building and Strengthening Public Health Impact, Systems, Capacity and Security $52,355
93.394 Cancer Detection and Diagnosis Research $52,086
93.879 Medical Library Assistance $43,007
93.307 Minority Health and Health Disparities Research $40,269
93.399 Cancer Control $38,218
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $37,947
93.855 Allergy and Infectious Diseases Research $34,361
93.233 National Center on Sleep Disorders Research $32,079
93.279 Drug Abuse and Addiction Research Programs $29,869
93.838 Lung Diseases Research $29,642
93.110 Maternal and Child Health Federal Consolidated Programs $28,219
93.084 Prevention of Disease, Disability, and Death by Infectious Diseases $26,058
93.866 Aging Research $25,443
84.063 Federal Pell Grant Program $21,084
93.134 Grants to Increase Organ Donations $20,030
93.080 Blood Disorder Program: Prevention, Surveillance, and Research $19,590
93.393 Cancer Cause and Prevention Research $18,827
64.RD Contract $18,387
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $15,989
93.226 Research on Healthcare Costs, Quality and Outcomes $15,212
93.173 Research Related to Deafness and Communication Disorders $14,198
47.049 Mathematical and Physical Sciences $13,338
93.396 Cancer Biology Research $11,790
93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response $11,769
93.398 Cancer Research Manpower $9,540
12.300 Basic and Applied Scientific Research $7,262
93.865 Child Health and Human Development Extramural Research $6,277
93.213 Research and Training in Complementary and Integrative Health $5,592
93.989 International Research and Research Training $4,316
47.076 Stem Education (formerly Education and Human Resources) $4,287
93.286 Discovery and Applied Research for Technological Innovations to Improve Human Health $4,164
93.846 Arthritis, Musculoskeletal and Skin Diseases Research $3,379
47.041 Engineering $888
93.867 Vision Research $314
12.420 Military Medical Research and Development $239
93.353 21st Century Cures Act - Beau Biden Cancer Moonshot $174
93.395 Cancer Treatment Research $81
43.001 Science $27