Criteria – In accordance with the Health Board’s grant award with the Portland Area Indian Health Service, Indian Health Service eligibility regulations require that grantees verify eligibility before providing services, and maintain records documenting such eligibility.
Condition and Context – The Health Board is required to maintain eligibility records for patients who receive services under the Urban Indian Health Services program. These records include Tribal enrollment and insurance coverage, among other things. We randomly selected 60 patients who received services during the audit period and noted the Health Board did not maintain Tribal enrollment documentation for 2 of the 60 patients tested.
Cause – The Health Board staff did not appear to be sufficiently trained to properly identify tribal enrollment documentation and ensure all required documents were obtained prior to providing services.
Effect – Individuals that are not eligible may have received services.
Questioned Costs – Questioned costs associated with this finding could not be determined.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board update polices and controls to include regular review of patient files. This may include review of the patient file for any outstanding Tribal enrollment and insurance documentation prior to scheduling the patients’ appointment.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a material weakness in internal control over compliance and material noncompliance. A sliding fee program was adopted that provides discounts to eligible patients and Indian tribes. A guideline was implemented to serve those who are federally eligible with documentation to support the assertions for eligibility and approval of the discount consideration. Staff are well-trained and are aware of the federal regulation that the Health Board will adhere to it and it is included in the policy. Considering a 3% error of the sample (2 out of 60) outcome of the audit, the Health Board feels it is immaterial. Management believes that there is adequate internal control that will safe guard the assets of the organization and comply with federal and local government regulations. While the expertise of the audit team is valued and insights are appreciated, the Health Board believes that labeling this finding as a material weakness does not accurately reflect the overall strength and effectiveness of the internal control over compliance.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – In accordance with the Health Board’s grant award with the Portland Area Indian Health Service, Indian Health Service eligibility regulations require that grantees verify eligibility before providing services, and maintain records documenting such eligibility.
Condition and Context – The Health Board is required to maintain eligibility records for patients who receive services under the Urban Indian Health Services program. These records include Tribal enrollment and insurance coverage, among other things. We randomly selected 60 patients who received services during the audit period and noted the Health Board did not maintain Tribal enrollment documentation for 2 of the 60 patients tested.
Cause – The Health Board staff did not appear to be sufficiently trained to properly identify tribal enrollment documentation and ensure all required documents were obtained prior to providing services.
Effect – Individuals that are not eligible may have received services.
Questioned Costs – Questioned costs associated with this finding could not be determined.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board update polices and controls to include regular review of patient files. This may include review of the patient file for any outstanding Tribal enrollment and insurance documentation prior to scheduling the patients’ appointment.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a material weakness in internal control over compliance and material noncompliance. A sliding fee program was adopted that provides discounts to eligible patients and Indian tribes. A guideline was implemented to serve those who are federally eligible with documentation to support the assertions for eligibility and approval of the discount consideration. Staff are well-trained and are aware of the federal regulation that the Health Board will adhere to it and it is included in the policy. Considering a 3% error of the sample (2 out of 60) outcome of the audit, the Health Board feels it is immaterial. Management believes that there is adequate internal control that will safe guard the assets of the organization and comply with federal and local government regulations. While the expertise of the audit team is valued and insights are appreciated, the Health Board believes that labeling this finding as a material weakness does not accurately reflect the overall strength and effectiveness of the internal control over compliance.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – In accordance with the Health Board’s grant award with the Portland Area Indian Health Service, Indian Health Service eligibility regulations require that grantees verify eligibility before providing services, and maintain records documenting such eligibility.
Condition and Context – The Health Board is required to maintain eligibility records for patients who receive services under the Urban Indian Health Services program. These records include Tribal enrollment and insurance coverage, among other things. We randomly selected 60 patients who received services during the audit period and noted the Health Board did not maintain Tribal enrollment documentation for 2 of the 60 patients tested.
Cause – The Health Board staff did not appear to be sufficiently trained to properly identify tribal enrollment documentation and ensure all required documents were obtained prior to providing services.
Effect – Individuals that are not eligible may have received services.
Questioned Costs – Questioned costs associated with this finding could not be determined.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board update polices and controls to include regular review of patient files. This may include review of the patient file for any outstanding Tribal enrollment and insurance documentation prior to scheduling the patients’ appointment.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a material weakness in internal control over compliance and material noncompliance. A sliding fee program was adopted that provides discounts to eligible patients and Indian tribes. A guideline was implemented to serve those who are federally eligible with documentation to support the assertions for eligibility and approval of the discount consideration. Staff are well-trained and are aware of the federal regulation that the Health Board will adhere to it and it is included in the policy. Considering a 3% error of the sample (2 out of 60) outcome of the audit, the Health Board feels it is immaterial. Management believes that there is adequate internal control that will safe guard the assets of the organization and comply with federal and local government regulations. While the expertise of the audit team is valued and insights are appreciated, the Health Board believes that labeling this finding as a material weakness does not accurately reflect the overall strength and effectiveness of the internal control over compliance.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – In accordance with the Health Board’s grant award with the Portland Area Indian Health Service, Indian Health Service eligibility regulations require that grantees verify eligibility before providing services, and maintain records documenting such eligibility.
Condition and Context – The Health Board is required to maintain eligibility records for patients who receive services under the Urban Indian Health Services program. These records include Tribal enrollment and insurance coverage, among other things. We randomly selected 60 patients who received services during the audit period and noted the Health Board did not maintain Tribal enrollment documentation for 2 of the 60 patients tested.
Cause – The Health Board staff did not appear to be sufficiently trained to properly identify tribal enrollment documentation and ensure all required documents were obtained prior to providing services.
Effect – Individuals that are not eligible may have received services.
Questioned Costs – Questioned costs associated with this finding could not be determined.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board update polices and controls to include regular review of patient files. This may include review of the patient file for any outstanding Tribal enrollment and insurance documentation prior to scheduling the patients’ appointment.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a material weakness in internal control over compliance and material noncompliance. A sliding fee program was adopted that provides discounts to eligible patients and Indian tribes. A guideline was implemented to serve those who are federally eligible with documentation to support the assertions for eligibility and approval of the discount consideration. Staff are well-trained and are aware of the federal regulation that the Health Board will adhere to it and it is included in the policy. Considering a 3% error of the sample (2 out of 60) outcome of the audit, the Health Board feels it is immaterial. Management believes that there is adequate internal control that will safe guard the assets of the organization and comply with federal and local government regulations. While the expertise of the audit team is valued and insights are appreciated, the Health Board believes that labeling this finding as a material weakness does not accurately reflect the overall strength and effectiveness of the internal control over compliance.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – In accordance with the Health Board’s grant award with the Portland Area Indian Health Service, Indian Health Service eligibility regulations require that grantees verify eligibility before providing services, and maintain records documenting such eligibility.
Condition and Context – The Health Board is required to maintain eligibility records for patients who receive services under the Urban Indian Health Services program. These records include Tribal enrollment and insurance coverage, among other things. We randomly selected 60 patients who received services during the audit period and noted the Health Board did not maintain Tribal enrollment documentation for 2 of the 60 patients tested.
Cause – The Health Board staff did not appear to be sufficiently trained to properly identify tribal enrollment documentation and ensure all required documents were obtained prior to providing services.
Effect – Individuals that are not eligible may have received services.
Questioned Costs – Questioned costs associated with this finding could not be determined.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board update polices and controls to include regular review of patient files. This may include review of the patient file for any outstanding Tribal enrollment and insurance documentation prior to scheduling the patients’ appointment.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a material weakness in internal control over compliance and material noncompliance. A sliding fee program was adopted that provides discounts to eligible patients and Indian tribes. A guideline was implemented to serve those who are federally eligible with documentation to support the assertions for eligibility and approval of the discount consideration. Staff are well-trained and are aware of the federal regulation that the Health Board will adhere to it and it is included in the policy. Considering a 3% error of the sample (2 out of 60) outcome of the audit, the Health Board feels it is immaterial. Management believes that there is adequate internal control that will safe guard the assets of the organization and comply with federal and local government regulations. While the expertise of the audit team is valued and insights are appreciated, the Health Board believes that labeling this finding as a material weakness does not accurately reflect the overall strength and effectiveness of the internal control over compliance.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – In accordance with the Health Board’s grant award with the Portland Area Indian Health Service, Indian Health Service eligibility regulations require that grantees verify eligibility before providing services, and maintain records documenting such eligibility.
Condition and Context – The Health Board is required to maintain eligibility records for patients who receive services under the Urban Indian Health Services program. These records include Tribal enrollment and insurance coverage, among other things. We randomly selected 60 patients who received services during the audit period and noted the Health Board did not maintain Tribal enrollment documentation for 2 of the 60 patients tested.
Cause – The Health Board staff did not appear to be sufficiently trained to properly identify tribal enrollment documentation and ensure all required documents were obtained prior to providing services.
Effect – Individuals that are not eligible may have received services.
Questioned Costs – Questioned costs associated with this finding could not be determined.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board update polices and controls to include regular review of patient files. This may include review of the patient file for any outstanding Tribal enrollment and insurance documentation prior to scheduling the patients’ appointment.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a material weakness in internal control over compliance and material noncompliance. A sliding fee program was adopted that provides discounts to eligible patients and Indian tribes. A guideline was implemented to serve those who are federally eligible with documentation to support the assertions for eligibility and approval of the discount consideration. Staff are well-trained and are aware of the federal regulation that the Health Board will adhere to it and it is included in the policy. Considering a 3% error of the sample (2 out of 60) outcome of the audit, the Health Board feels it is immaterial. Management believes that there is adequate internal control that will safe guard the assets of the organization and comply with federal and local government regulations. While the expertise of the audit team is valued and insights are appreciated, the Health Board believes that labeling this finding as a material weakness does not accurately reflect the overall strength and effectiveness of the internal control over compliance.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – In accordance with the Health Board’s grant award with the Portland Area Indian Health Service, Indian Health Service eligibility regulations require that grantees verify eligibility before providing services, and maintain records documenting such eligibility.
Condition and Context – The Health Board is required to maintain eligibility records for patients who receive services under the Urban Indian Health Services program. These records include Tribal enrollment and insurance coverage, among other things. We randomly selected 60 patients who received services during the audit period and noted the Health Board did not maintain Tribal enrollment documentation for 2 of the 60 patients tested.
Cause – The Health Board staff did not appear to be sufficiently trained to properly identify tribal enrollment documentation and ensure all required documents were obtained prior to providing services.
Effect – Individuals that are not eligible may have received services.
Questioned Costs – Questioned costs associated with this finding could not be determined.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board update polices and controls to include regular review of patient files. This may include review of the patient file for any outstanding Tribal enrollment and insurance documentation prior to scheduling the patients’ appointment.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a material weakness in internal control over compliance and material noncompliance. A sliding fee program was adopted that provides discounts to eligible patients and Indian tribes. A guideline was implemented to serve those who are federally eligible with documentation to support the assertions for eligibility and approval of the discount consideration. Staff are well-trained and are aware of the federal regulation that the Health Board will adhere to it and it is included in the policy. Considering a 3% error of the sample (2 out of 60) outcome of the audit, the Health Board feels it is immaterial. Management believes that there is adequate internal control that will safe guard the assets of the organization and comply with federal and local government regulations. While the expertise of the audit team is valued and insights are appreciated, the Health Board believes that labeling this finding as a material weakness does not accurately reflect the overall strength and effectiveness of the internal control over compliance.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – In accordance with the Health Board’s grant award with the Portland Area Indian Health Service, Indian Health Service eligibility regulations require that grantees verify eligibility before providing services, and maintain records documenting such eligibility.
Condition and Context – The Health Board is required to maintain eligibility records for patients who receive services under the Urban Indian Health Services program. These records include Tribal enrollment and insurance coverage, among other things. We randomly selected 60 patients who received services during the audit period and noted the Health Board did not maintain Tribal enrollment documentation for 2 of the 60 patients tested.
Cause – The Health Board staff did not appear to be sufficiently trained to properly identify tribal enrollment documentation and ensure all required documents were obtained prior to providing services.
Effect – Individuals that are not eligible may have received services.
Questioned Costs – Questioned costs associated with this finding could not be determined.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board update polices and controls to include regular review of patient files. This may include review of the patient file for any outstanding Tribal enrollment and insurance documentation prior to scheduling the patients’ appointment.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a material weakness in internal control over compliance and material noncompliance. A sliding fee program was adopted that provides discounts to eligible patients and Indian tribes. A guideline was implemented to serve those who are federally eligible with documentation to support the assertions for eligibility and approval of the discount consideration. Staff are well-trained and are aware of the federal regulation that the Health Board will adhere to it and it is included in the policy. Considering a 3% error of the sample (2 out of 60) outcome of the audit, the Health Board feels it is immaterial. Management believes that there is adequate internal control that will safe guard the assets of the organization and comply with federal and local government regulations. While the expertise of the audit team is valued and insights are appreciated, the Health Board believes that labeling this finding as a material weakness does not accurately reflect the overall strength and effectiveness of the internal control over compliance.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – In accordance with the Health Board’s grant award with the Portland Area Indian Health Service, Indian Health Service eligibility regulations require that grantees verify eligibility before providing services, and maintain records documenting such eligibility.
Condition and Context – The Health Board is required to maintain eligibility records for patients who receive services under the Urban Indian Health Services program. These records include Tribal enrollment and insurance coverage, among other things. We randomly selected 60 patients who received services during the audit period and noted the Health Board did not maintain Tribal enrollment documentation for 2 of the 60 patients tested.
Cause – The Health Board staff did not appear to be sufficiently trained to properly identify tribal enrollment documentation and ensure all required documents were obtained prior to providing services.
Effect – Individuals that are not eligible may have received services.
Questioned Costs – Questioned costs associated with this finding could not be determined.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board update polices and controls to include regular review of patient files. This may include review of the patient file for any outstanding Tribal enrollment and insurance documentation prior to scheduling the patients’ appointment.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a material weakness in internal control over compliance and material noncompliance. A sliding fee program was adopted that provides discounts to eligible patients and Indian tribes. A guideline was implemented to serve those who are federally eligible with documentation to support the assertions for eligibility and approval of the discount consideration. Staff are well-trained and are aware of the federal regulation that the Health Board will adhere to it and it is included in the policy. Considering a 3% error of the sample (2 out of 60) outcome of the audit, the Health Board feels it is immaterial. Management believes that there is adequate internal control that will safe guard the assets of the organization and comply with federal and local government regulations. While the expertise of the audit team is valued and insights are appreciated, the Health Board believes that labeling this finding as a material weakness does not accurately reflect the overall strength and effectiveness of the internal control over compliance.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – In accordance with the Health Board’s grant award with the Portland Area Indian Health Service, Indian Health Service eligibility regulations require that grantees verify eligibility before providing services, and maintain records documenting such eligibility.
Condition and Context – The Health Board is required to maintain eligibility records for patients who receive services under the Urban Indian Health Services program. These records include Tribal enrollment and insurance coverage, among other things. We randomly selected 60 patients who received services during the audit period and noted the Health Board did not maintain Tribal enrollment documentation for 2 of the 60 patients tested.
Cause – The Health Board staff did not appear to be sufficiently trained to properly identify tribal enrollment documentation and ensure all required documents were obtained prior to providing services.
Effect – Individuals that are not eligible may have received services.
Questioned Costs – Questioned costs associated with this finding could not be determined.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board update polices and controls to include regular review of patient files. This may include review of the patient file for any outstanding Tribal enrollment and insurance documentation prior to scheduling the patients’ appointment.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a material weakness in internal control over compliance and material noncompliance. A sliding fee program was adopted that provides discounts to eligible patients and Indian tribes. A guideline was implemented to serve those who are federally eligible with documentation to support the assertions for eligibility and approval of the discount consideration. Staff are well-trained and are aware of the federal regulation that the Health Board will adhere to it and it is included in the policy. Considering a 3% error of the sample (2 out of 60) outcome of the audit, the Health Board feels it is immaterial. Management believes that there is adequate internal control that will safe guard the assets of the organization and comply with federal and local government regulations. While the expertise of the audit team is valued and insights are appreciated, the Health Board believes that labeling this finding as a material weakness does not accurately reflect the overall strength and effectiveness of the internal control over compliance.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.
Criteria – Federal regulations and grant terms and conditions of the programs require annual fiscal reports be submitted to the awarding agencies. In accordance with Uniform Guidance 2 CFR 200.303 the Health Board should have internal controls established to ensure accuracy of information reported and ensure compliance with reporting requirements. Additionally, good internal controls require that an individual who did not prepare the report should review the report for accuracy prior to submission.
Condition and Context – The annual SF-425 reports required under each program were submitted, but we noted no evidence of secondary review by an individual other than the preparer. As a result, the submitted SF-425 reports misreported total program expenditures for the period and the reports were ultimately rejected by the funding agencies causing the Health Board’s accounting department to correct and re-submit SF-425 reports subsequent to the period under audit.
Cause – The Health Board does not have sufficient internal controls over their grant reporting process to ensure proper review of report prior to submission to ensure all reported information is accurate.
Effect – There is an increased likelihood of errors in the information reported to federal agencies and ultimately an increased likelihood of noncompliance over reporting requirements.
Questioned Costs – There were no questioned costs associated with this finding.
Repeat Finding – This is not a repeat finding.
Recommendation – We recommend the Health Board improve the controls over the reporting function, which includes the documentation, review, and approval of all required reports.
Views of responsible officials – Management agrees with the auditors' findings and will implement the corrective action plan to address the issue identified.
Criteria – Federally funded entities must establish internal control procedures over compliance with provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that require, among other things, that direct charges to federal awards be for allowable costs. To be an allowable cost, charges must be supported by appropriate documentation and be properly approved.
Condition and Context – Employee payroll costs are charged to programs based on an approved timesheet, and an allocation rate and pay rate approved through each employee’s personnel action for action form. For pay periods spanning reporting periods the Health Board allocates employee payroll costs to each reporting period based on the number of days of each reporting period included in the pay period.
The first payroll subsequent to year-end covered the period September 25, 2023 through October 8, 2023. This pay period included six days of fiscal year 2023 and eight days of fiscal year 2024. However, the Health Board incorrectly accrued eight days of payroll costs to fiscal year 2023, thereby overcharging the programs.
Cause – It appears this deficiency was caused by inadequate internal controls over the year-end payroll accrual calculation.
Effect – Without strong internal controls over payroll unallowable expenditures could be charged to a federally funded program.
Questioned Costs – This control deficiency resulted in the following questioned costs;
• AL Number 93.193 – Known questioned costs were $49,659
• AL Number 93.479 – Known questioned costs were $1,613
• AL Number 93.231 – Known questioned costs were $11,355
Since we evaluated 100% of the year-end accrued payroll there are no likely questioned costs.
Repeat Finding – No
Recommendation – We recommend the Health Board improve the controls over the payroll, to ensure year-end accrual amounts are properly calculated.
Views of responsible officials – Management respectfully disagrees with the characterization of the finding as a significant deficiency in internal control over compliance and another matter. Management believes the internal control processes and reviews currently in place are effective. Management will implement the additional review step identified in the corrective action plan to further enhance the internal control.