American College of Obstetricians and Gynocologists

Information on the Major Federal Program ? Department of Health and Human Services Assistance Listing Number: 93.421 Assistance Listing Name: Strengthening Public Health Systems and Services through National Partnerships to Improve and Protect the Nation?s Health Program Title Award Number Award Period American Academy of Pediatrics ? Assessing the Acceptability and Feasibility of Vaccinate with Confidence Material Use in Obstetric Clinics 6 NU38OT000282-03-01 January 15, 2021 ? July 31, 2021 Category C: Pediatric Health Care Clinicians 6 NU38OT000287-04-03 August 1, 2018 ? July 31, 2023 Criteria - In accordance with the requirements of 2 CFR ?1402.300, the non-Federal entity is responsible for complying with all requirements of the Federal award. For all Federal awards, this includes the provisions of the Federal Funding and Accountability Act (FFATA), which includes requirements on executive compensation, and also requirements implementing the Act for the non-Federal entity at 2 CFR part 25, Financial Assistance Use of Universal Identifier and System for Award Management and 2 CFR part 170, Reporting Subaward and Executive Compensation Information. In accordance with 2 CFR Part 170, Appendix A, under FFATA, the Organization is required to collect and report information on each subaward or amendment of $30,000 or more in federal funds in the FFATA Subaward Reporting System. Condition - During our testing of reporting, we selected three subrecipient subawards. For one sample tested, there were no actions taken to perform the mandatory FFATA requirements. Transactions Tested Subaward not reported Report not timely Subaward amount incorrect Subaward missing key elements 3 1 1 Not applicable- No report was submitted Not applicable- No report was submitted Dollar Amount of Tested 2021 Subawards Subaward not reported Report not timely Subaward amount incorrect Subaward missing key elements $48,000 $33,000 $33,000 Not applicable- No report was submitted Not applicable- No report was submittedCause ? The Organization does not have adequate policies and procedures in place to ensure compliance with the requirements regarding reporting. Effect or Potential Effect - Failure to comply with the reporting requirements of the Uniform Guidance could result in the awarding agency taking action such as reducing future funding. Questioned Costs - None. Context - This is a condition identified based upon our review of the Organization?s compliance with specified requirements. The sample was selected based on a non-statistical basis. The prevalence of these findings is detailed in the condition section above. Repeat finding ? This is not a repeat finding. Recommendation ? BDO recommends that the Organization immediately establish policies and procedures to ensure FFATA requirements are satisfied for subrecipients meeting the requirements. Views of Responsible Officials - Management is developing formal, written procedures regarding FFATA reporting requirements to ensure reports are submitted timely and accurate.

2020-001 Subrecipient Monitoring Information on Federal Program - United States Department of Health and Human Services CFDA Number: 93.110 CFDA Name: Material and Child Health Federal Consolidated Programs [See Schedule of Findings and Questioned Costs for chart with program title, award number and award period] Criteria - In accordance with ?200.303(a), Internal Controls, a non-federal entity must 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. In accordance with ?200.331(a) Requirements for Pass-Through Entities requires that pass-through entities must ensure that every sub-award is clearly identified to the subrecipient as a sub-award and includes certain information at the time of the subaward, and if any of the required data elements change, the pass-through entity must include the changes in subsequent subaward modifications. In accordance with ?200.331(b), ?200.331(d), and ?200.331(f), Requirements for Pass-Through Entities, the Organization must evaluate each subrecipient?s risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring. The Organization must also 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 subaward performance goals are achieved. Pass-through entity monitoring of the subrecipient must include: (1) reviewing financial and performance reports required by the pass-through entity; (2) following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and other means; and (3) issuing a management decision for audit findings pertaining to the federal award provided to the subrecipient from the pass-through entity. Additionally, pass-through entities must verify that every subrecipient is audited as required by Subpart F ? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501, Audit Requirements. Condition - During our testing of subrecipient monitoring, we noted the following conditions: ? For 1 of 6 subrecipient samples, the Organization did not include the indirect cost rate within the subrecipient agreement which is a requirement under the Uniform Guidance. This resulted from the Organization not updating ongoing subrecipient agreements to include required information through the use of subaward modifications. [See Schedule of Findings and Questioned Costs for chart with program title, award number and noncompliance instances] ? For 5 of 6 subrecipient samples, the Organization did not fully complete the risk and monitoring plan assessment form developed by management. The Organization was able to provide documentation during the audit to support the subrecipients risk level and degree of monitoring procedures performed. [See Schedule of Findings and Questioned Costs for chart with program title, award number and noncompliance instances] Cause ? Personnel did not adhere to the Organization?s documented subrecipient policies and procedures for subrecipient audit requirements. Effect or Potential Effect - Failure to comply with the subrecipient monitoring requirement of the Uniform Guidance could result in unallowable expenses being charged to the grants by the subrecipients. Questioned Costs - Not determinable. Context - This is a condition identified per review of the Organization?s compliance with specified requirements using a randomly selected sample. The prevalence of these findings is detailed in the condition section above. Repeat finding ? This is a repeat finding from the previous year. This was reported as finding 2019- 003 in the 2019 schedule of findings and questioned costs. Recommendation - The adherence to the Organization?s documented subrecipient policies and procedures, including the completion of the updated subrecipient checklist would ensure subrecipient monitoring requirements are met. BDO also recommends that the Organization implement a process by which supporting documentation for subrecipient monitoring and risk assessment procedures performed is maintained in a centralized location. Views of Responsible Officials ? The Organization?s Finance Department enhanced its formal written policies and procedures regarding subrecipient monitoring in 2020. Supplemental forms were designed, and checklists created, to identify needed actions to ensure subrecipient monitoring requirements are met. To accomplish these goals management: ? Revised the subrecipient monitoring checklist to include procuring and reviewing any findings in the subrecipient?s Single Audit report. ? Developed site visit criteria and a site visit checklist. Performed subrecipient site visits when appropriate. These new policies and procedures became effective during 2020. The Organization also initiated a project to review past documentation to ensure completeness with the enhanced policies. Due to staff transitions during the year, this project was not completed for all subrecipients prior to the audit. Management has prioritized this project to be completed for all active subrecipients by June 30, 2021.

2020-002 Reporting - Performance Reporting Information on Federal Program - United States Department of Health and Human Services CFDA Number: 93.110 CFDA Name: Material and Child Health Federal Consolidated Programs [See Schedule of Findings and Questioned Costs for chart with program title, award number and award period] Criteria - In accordance with ?200.303(a), Internal Controls, a non-federal entity must 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. Condition ? During the testing of programmatic reports, programmatic personnel were unable to provide documentation that the performance report had been reviewed and approved prior to submission. Cause - The internal controls established for review of programmatic reports did not operate as designed. However, the information within the programmatic reports was accurate based on our testing. Effect or Potential Effect ? Failure to perform oversight and approval of programmatic reports could result in the Organization providing information to the federal government that is incomplete or inaccurate which could lead to delayed funding. Questioned Costs ? There are no questioned costs related to the items described above. Context - We tested a sample of three programmatic reports and found one exception. This is a condition identified per review of the Organization?s internal controls over compliance using a randomly selected sample. Repeat finding ? This is a repeat finding from the previous year. This was reported as finding 2019- 004 in the 2019 schedule of findings and questioned costs. Recommendation - We recommend that management implement a process by which approvals, submission considerations and supporting documentation for programmatic reports is maintained in a centralized location. Views of Responsible Officials - Management has developed formal written policies, procedures, and a process for the documentation, review, and approval of cooperative and grant performance reports prior to submission. Specific program staff are assigned the responsibility for preparation, review and approval, and submission of programmatic reports. Programmatic reports are prepared by the grant team but in this instance, no written report approval was retained. The grant compliance manager will perform additional training with all grant staff to review the roles and responsibilities and emphasize the requirement to maintain documentation of report approval prior to submission.

2020-003 Reporting Information on Federal Program - United States Department of Health and Human Services CFDA Number: 93.110 CFDA Name: Material and Child Health Federal Consolidated Programs [See Schedule of Findings and Questioned Costs for chart with program title, award number and award period] Criteria - In accordance with ?200.510(b) states in part: ?The auditee must also prepare a schedule of expenditures of Federal awards (the Schedule) for the period covered by the auditee?s financial statements which must include the total Federal awards expended as determined in accordance with ?200.502, Basis for determining Federal awards expended?. The schedule must provide total Federal awards expended for each individual Federal program. Condition ? During our review of the procurement population, we noted 13 subrecipients were improperly classified as vendors. These expenditures were excluded from the subrecipient population and not properly included within the subrecipient expenditure column of the Schedule originally provided by management. While information between the populations and the Schedule was not properly reconciled in regard to subrecipients, the Organization maintained documentation for these subrecipients and appropriately identified them as subrecipients at contract inception per review of supporting documentation provided. During our review of grant agreements, we noted one Federal award totaling $99,179 that was improperly excluded from the original Schedule. This resulted in an understatement of total Federal awards expended as presented on the Schedule. There was no impact to the major program. Cause - The Organization experienced staffing constraints during the year-end closing and financial reporting time period, which put a strain on management?s ability to prepare an accurate Schedule. Insufficient understanding of the basis for determining Federal awards expended resulted in an inaccurate Schedule. Effect or Potential Effect - The original Schedule provided excluded expenditures for 13 subrecipients within the subrecipient expenditure column and as a result, the Schedule was not properly stated. Adjustments were recorded and approved by the Organization?s management for presentation in this report. Questioned Costs ? There are no questioned costs related to this finding. Context ? The inaccurate subrecipient expenses disclosed within the Schedule was identified through procurement testing. Per review of the Organization?s grant agreements, we identified one grant that was improperly excluded from the Schedule. Repeat finding ? This is a repeat finding from the previous year. This was reported as finding 2019- 005 in the 2019 schedule of findings and questioned costs. Recommendation - We recommend that the Organization strengthen policies and procedures to ensure that Federal funds used by subrecipients are reported accurately on the schedule of expenditures of federal awards. We recommend that individuals responsible for administering Federal programs within the Organization obtain training related to Federal grant requirements. Views of Responsible Officials ? The Organization accurately classified subrecipients and vendors during the year in accordance with the Organization?s policies and procedures. However, staff provided the Schedule of Expenditures of Federal Awards to the auditors that was incomplete and had not been through the final review process as required in our procedures. Once all required reviews had taken place, the Schedule of Expenditures of Federal Awards was complete and accurate. The Grant Compliance Manager will perform additional staff training on the audit process and procedures required to be performed on the Schedule of Expenditures of Federal Awards.

Information on Federal Program ? United States Department of Health and Human Services CFDA Number: 93.110 CFDA Name: Material and Child Health Federal Consolidated Programs Program Title Award Number Award Period Alliance for Innovation on Maternal and Child Health UC4MC28042 September 1, 2014 ? August 31, 2023 Bright Futures for Women?s Health UH0MC29440 March 1, 2016 ? February 28, 2021 United States Department of Health and Human Services CFDA Number: 93.421 CFDA Name: Strengthening Public Health Systems and Services through National Partnerships to Improve and Protect the Nation?s Health Program Title Award Number Award Period American Academy of Pediatrics - Maternal-Infant Health and Opioid Use 5 NU38OT000282 January 1, 2019 ? July 31, 2020 Category C: Pediatric Health Care Clinicians 6 NU38OT000287 August 1, 2018 ? July 31, 2023 Criteria ? In accordance with ?200.318(a), General Procurement Standards, the non-federal entity must use its own documented procurement procedures which reflect applicable State, local, and tribal laws and regulations, provided that the procurements conform to applicable federal law and the standards identified in General Procurement Standards. In accordance with ?200.213 and ?180.300, Suspension and Debarment, non-federal entities cannot enter into awards, subawards, or contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities. Non-federal entities must either check for exclusions in the System for Award Management (SAM); collect a certification from the entity or add a clause or condition to the covered transaction with the entity prior to entering into a covered transaction with a non-federal entity. Condition ? During our review of the Organization?s procurement policies, we noted that the Organization?s current internal procurement policies and procedures do not conform to the requirements identified in General Procurement Standards. For one of two procurement transactions tested [CFDA 93.110], we noted the required debarment and suspension analysis was performed subsequent to entering into the contract with the vendor. The Organization?s subsequent suspension and debarment analysis identified that the vendor was not suspended or debarred. Cause ? Personnel did not adhere to the Organization?s documented policies and procedures for entering into procurement contracts. In addition, the Organization?s written internal procurement policies and procedures do not conform to the requirements identified in General Procurement Standards. Effect or Potential Effect - Failure to verify that a vendor is not suspended or debarred could result in unintentionally entering into a contract with and disbursing federal funds to an entity that is barred from performing work for the federal government. Failure to comply with the General Procurement Standards as outlined in the Uniform Administrative Requirements could result in expenditures made being disallowed. Questioned Costs ? Not determinable. Context ? This is a condition based on testing of the Organization?s compliance with specified requirements. The samples were selected using a non-statistical method. Repeat finding ? This is a repeat finding from the previous year. This was reported as finding 2018-002 in the 2018 schedule of findings and questioned costs. Recommendation ? We recommend that management revise the internal procurement policies and procedures to conform to the requirements identified in General Procurement Standards. Views of Responsible Officials - Management agrees with this finding. The Organization reviewed CFR 200.318 and modified its policies to conform to the General Procurement Standards in the Uniform Guidance, effective February 2020. Management will ensure that required documentation, including the suspension and debarment analysis, accompany contracts before they are signed.

Information on Federal Program - United States Department of Health and Human Services CFDA Number: 93.110 CFDA Name: Material and Child Health Federal Consolidated Programs Program Title Award Number Award Period Alliance for Innovation on Maternal and Child Health UC4MC28042 September 1, 2014 ? August 31, 2023 Bright Futures for Women?s Health UH0MC29440 March 1, 2016 ? February 28, 2021 United States Department of Health and Human Services CFDA Number: 93.421 CFDA Name: Strengthening Public Health Systems and Services through National Partnerships to Improve and Protect the Nation?s Health Program Title Award Number Award Period American Academy of Pediatrics - Maternal-Infant Health and Opioid Use 5 NU38OT000282 January 1, 2019 ? July 31, 2020 Category C: Pediatric Health Care Clinicians 6 NU38OT000287 August 1, 2018 ? July 31, 2023 Criteria - In accordance with ?200.303(a), Internal Controls, a non-federal entity must 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. In accordance with ?200.331(a) Requirements for Pass-Through Entities requires that pass-through entities must ensure that every sub-award is clearly identified to the subrecipent as a sub-award and includes certain information at the time of the subaward, and if any of the required data elements change, the pass-through entity must include the changes in subsequent subaward modifications. In accordance with ?200.331(b), ?200.331(d), and ?200.331(f), Requirements for Pass-Through Entities, the Organization must evaluate each subrecipient?s risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring. The Organization must also 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 subaward performance goals are achieved. Pass-through entity monitoring of the subrecipient must include: (1) reviewing financial and performance reports required by the pass-through entity; (2) following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and other means; and (3) issuing a management decision for audit findings pertaining to the federal award provided to the subrecipient from the pass-through entity. Additionally, pass-through entities must verify that every subrecipient is audited as required by Subpart F ? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501, Audit Requirements. Condition - During our testing of subrecipient monitoring, we noted the following conditions: ? For 1 of 10 subrecipient samples, the Organization did not verify that the subrecipient had an audit performed, nor did management review the results of such subrecipient audit as part of their on-going monitoring procedures. Program Title Award Number Noncompliance Category C: Pediatric Health Care Clinicians 6 NU38OT000287 1 instance ? For 4 of 10 subrecipient samples, the Organization did not include requirements under the Uniform Guidance within the subrecipient agreement. This resulted from the Organization not utilizing the updated subrecipient award template developed by management which mandates such information, and not updating ongoing subrecipient agreements to include required information through the use of subaward modifications. Program Title Award Number Noncompliance Alliance for Innovation on Maternal and Child Health UC4MC28042 3 instances Bright Futures for Women?s Health UH0MC29440 1 instance ? For 3 of 10 subrecipient samples, there was no evidence that the financial and programmatic subrecipient reports were reviewed by the Organization. Program Title Award Number Noncompliance Alliance for Innovation on Maternal and Child Health UC4MC28042 3 instances ? For 3 of 10 subrecipient samples, there was no evidence to support that a risk assessment had been performed or that a monitoring and evaluation plan had been developed by the Organization. This resulted from the Organization not fully completing the risk assessment form developed by management. Program Title Award Number Noncompliance Alliance for Innovation on Maternal and Child Health UC4MC28042 3 instances ? For 5 of 10 subrecipient samples, there was insufficient evidence to support that monitoring procedures were performed subsequent to the execution date of the subrecipient agreement. Program Title Award Number Noncompliance Alliance for Innovation on Maternal and Child Health UC4MC28042 4 instances Category C: Pediatric Health Care Clinicians 6 NU38OT000287 1 instance Cause ? Personnel did not adhere to the Organization?s documented subrecipient policies and procedures for subrecipient audit requirements. Effect or Potential Effect - Failure to comply with the subrecipient monitoring requirement of the Uniform Guidance could result in unallowable expenses being charged to the grants by the subrecipients. Questioned Costs - Not determinable. Context - This is a condition identified per review of the Organization?s compliance with specified requirements using a randomly selected sample. The prevalence of these findings is detailed in the condition section above. Repeat finding ? This is a repeat finding from the previous year. This was reported as finding 2018-003 in the 2018 schedule of findings and questioned costs. Recommendation - The revision of the current subrecipient checklist could assist grant personnel with following the policies and procedures and ensure subrecipient monitoring requirements are met. BDO also recommends that the Organization implement a process by which supporting documentation for subrecipient monitoring and risk assessment procedures performed is maintained in a centralized location. Views of Responsible Officials - Management agrees with this finding and has enhanced its formal written policies and procedures regarding subrecipient monitoring. Supplemental forms have been designed, and checklists created, to identify needed actions to ensure subrecipient monitoring requirements are met and documented. The Organization has hired a Grants Compliance Manager with extensive subrecipient compliance knowledge to oversee the subrecipient monitoring process. The Organization has also implemented regular training for all grant staff on compliance requirements.

Information on Federal Program - United States Department of Health and Human Services CFDA Number: 93.110 CFDA Name: Material and Child Health Federal Consolidated Programs Program Title Award Number Award Period Alliance for Innovation on Maternal and Child Health UC4MC28042 September 1, 2014 ? August 31, 2023 Bright Futures for Women?s Health UH0MC29440 March 1, 2016 ? February 28, 2021 Criteria - In accordance with ?200.303(a), Internal Controls, a non-federal entity must 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. Condition ? During the testing of programmatic reports, programmatic personnel were unable to provide documentation that the performance report had been reviewed and approved prior to submission. Cause - The internal controls established for review of programmatic reports did not operate as designed. However, the information within the programmatic reports was accurate based on our testing. Effect or Potential Effect ? Failure to perform oversight and approval of programmatic reports could result in the Organization providing information to the federal government that is incomplete or inaccurate which could lead to delayed funding. Questioned Costs ? There are no questioned costs related to the items described above. Context - We tested a sample of three programmatic reports and found two exceptions. This is a condition identified per review of the Organization?s internal controls over compliance using a randomly selected sample. Repeat finding ? This is a repeat finding from the previous year. This was reported as finding 2018-004 in the 2018 schedule of findings and questioned costs. Recommendation - We recommend that management implement a process by which approvals, submission considerations and supporting documentation for programmatic reports is maintained in a centralized location. Views of Responsible Officials - Management agrees with this finding and has developed formal written policies, procedures, and a process for the documentation, review, and approval of cooperative and grant performance reports prior to submission. Specific program staff are assigned the responsibility for preparation, review and approval, and submission of programmatic reports. The policy ensures documentation and tracking, how often reports will be prepared, to whom will they go at the funding agency, and when the reports are due. Electronic folders are available to program staff and financial grant management staff to maintain and store the reports and supporting documentation.

Information on Federal Program - United States Department of Health and Human Services CFDA Number: 93.110 CFDA Name: Material and Child Health Federal Consolidated Programs Program Title Award Number Award Period Alliance for Innovation on Maternal and Child Health UC4MC28042 September 1, 2014 ? August 31, 2023 Bright Futures for Women?s Health UH0MC29440 March 1, 2016 ? February 28, 2021 Criteria - In accordance with ?200.510(b) states in part: ?The auditee must also prepare a schedule of expenditures of Federal awards (the Schedule) for the period covered by the auditee?s financial statements which must include the total Federal awards expended as determined in accordance with ?200.502, Basis for determining Federal awards expended?. The schedule must provide total Federal awards expended for each individual Federal program. Condition ? During our review of the procurement population, we noted one subrecipient was classified as a vendor. These expenditures were excluded from the subrecipient population and not properly included within the subrecipient expenditure column of the Schedule originally provided by the client. During our review of grant agreements, we noted one Federal award that was improperly excluded from the original Schedule. This resulted in one program on the original Schedule provided for the audit to be understated in Federal awards expended. Cause - The Organization experienced staffing constraints during the year-end closing and financial reporting time period, which put a strain on management?s ability to prepare an accurate Schedule. Insufficient understanding of the basis for determining Federal awards expended resulted in an inaccurate Schedule. Effect or Potential Effect - The original Schedule provided excluded expenditures for one subrecipient within the subrecipient expenditure column. The original Schedule provided was inaccurate. Adjustments were recorded and approved by the Organization?s management for presentation in this report. Questioned Costs ? There are no questioned costs related to this finding. Context ? The incomplete subrecipient population was identified through procurement testing. Per review of the Organization?s grant agreements, we identified one grant that was improperly excluded from the Schedule. Repeat finding ? This is a repeat finding from the previous year. This was reported as finding 2018-005 in the 2018 schedule of findings and questioned costs. Recommendation - We recommend that the Organization strengthen policies and procedures to ensure that Federal funds used by subrecipients are reported accurately on the schedule of expenditures of federal awards. We recommend that individuals responsible for administering Federal programs within the Organization obtain training related to Federal grant requirements. Views of Responsible Officials - The grants management team experienced turnover in 2018 and 2019. The Organization hired a grants compliance manager in 2019 to provide a higher level of expertise and oversight to the grants management process. Processes now include review and documentation of subrecipient / contractor determination, disclosure requirements to subrecipients and accuracy of the schedule of expenditures of federal awards.

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