Audit 2149

Information on Federal Program(s) - Department of Health and Human Services, Assistance Listing Number 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan Rural Distribution, Schedule of Expenditures of Federal Awards Reporting Periods 2 and 3, Agency Fiscal Year-Ended June 30, 2022. Criteria – The Code of Federal Regulations Section 200.403(g) states that for costs to be allowable under Federal awards, they must be adequately documented. Pursuant to 2 CFR section 200.303(a), the nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition – During our testing of direct expenditures, we noted the following exceptions: • Two of the sixty expenditures sampled did not have necessary approvals. The original invoices with approvals could not be found, however we were able to determine that the invoices were properly recorded to the general ledger. • Two of the sixty expenditures sampled did not have adequate supporting documentation. • Two of the sixty expenditures had supporting documentation that was coded to cost centers and/or accounts that were inconsistent with what was recorded in the general ledger. However, the actual postings to the general ledger were recorded to the correct cost centers and/or accounts. Cause - Policies and procedures were not appropriately adhered to in certain instances to ensure that supporting documentation was maintained correctly to evidence that costs were allowable and that an appropriate level of review and approval was completed prior to charging costs to a federal program. Effect or Potential Effect - We were unable to confirm the allowability, validity, or completeness of the two expenses lacking supporting documentation that were claimed as federal expenditures. Questioned Costs – Likely questioned costs were projected to be less than $25,000 based on the sampling procedures that were performed. Context – We tested a sample of forty direct expense transactions using a statistically valid sample and found four exceptions relating to the absence of supporting documentation and/or necessary approvals. At that point, a significant deficiency was raised and we revised our risk assessment over compliance and determined it to be high risk. We then selected an additional twenty direct expense transactions using a statistically valid sample and found two additional exceptions relating to improper adherence to certain activity level controls, however, no additional compliance deviations were identified. Views of Responsible Officials – The nature of the COVID emergency, and local shutdown orders, as well as the timing of the funding made available to prevent the viruses spread, challenged long established and effective internal control procedures. In response the Agency, under the direction of the Controller, created emergency overrides to existing protocols to be administered within the accounting department that in the cases above were not documented as they would have been under non-emergency circumstances. In order to mitigate the possible impact of these emergency overrides a detailed review for reasonableness of all items funded with the funds appropriated was performed by the Controller prior to the completion of the audit. Internal control procedures for use in future emergency situations will be developed that will address the deficiencies or challenges identified above. Recommendation - We recommend that the Agency ensure its policies and procedures are followed on a consistent basis and for emergency situations, have alternative policies and procedures that can be implemented without delay.

Information on Federal Program(s) - Department of Health and Human Services, Assistance Listing Number 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan Rural Distribution, Schedule of Expenditures of Federal Awards Reporting Periods 2 and 3, Agency Fiscal Year-Ended June 30, 2022. Criteria – The Code of Federal Regulations Section 200.403(g) states that for costs to be allowable under Federal awards, they must be adequately documented. Pursuant to 2 CFR section 200.303(a), the nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition – During our testing of direct expenditures, we noted the following exceptions: • Two of the sixty expenditures sampled did not have necessary approvals. The original invoices with approvals could not be found, however we were able to determine that the invoices were properly recorded to the general ledger. • Two of the sixty expenditures sampled did not have adequate supporting documentation. • Two of the sixty expenditures had supporting documentation that was coded to cost centers and/or accounts that were inconsistent with what was recorded in the general ledger. However, the actual postings to the general ledger were recorded to the correct cost centers and/or accounts. Cause - Policies and procedures were not appropriately adhered to in certain instances to ensure that supporting documentation was maintained correctly to evidence that costs were allowable and that an appropriate level of review and approval was completed prior to charging costs to a federal program. Effect or Potential Effect - We were unable to confirm the allowability, validity, or completeness of the two expenses lacking supporting documentation that were claimed as federal expenditures. Questioned Costs – Likely questioned costs were projected to be less than $25,000 based on the sampling procedures that were performed. Context – We tested a sample of forty direct expense transactions using a statistically valid sample and found four exceptions relating to the absence of supporting documentation and/or necessary approvals. At that point, a significant deficiency was raised and we revised our risk assessment over compliance and determined it to be high risk. We then selected an additional twenty direct expense transactions using a statistically valid sample and found two additional exceptions relating to improper adherence to certain activity level controls, however, no additional compliance deviations were identified. Views of Responsible Officials – The nature of the COVID emergency, and local shutdown orders, as well as the timing of the funding made available to prevent the viruses spread, challenged long established and effective internal control procedures. In response the Agency, under the direction of the Controller, created emergency overrides to existing protocols to be administered within the accounting department that in the cases above were not documented as they would have been under non-emergency circumstances. In order to mitigate the possible impact of these emergency overrides a detailed review for reasonableness of all items funded with the funds appropriated was performed by the Controller prior to the completion of the audit. Internal control procedures for use in future emergency situations will be developed that will address the deficiencies or challenges identified above. Recommendation - We recommend that the Agency ensure its policies and procedures are followed on a consistent basis and for emergency situations, have alternative policies and procedures that can be implemented without delay.