Finding Number 2023-002: Timesheet vs. Time Study Hours (Significant Deficiency over Internal Control
and Instance of Noncompliance – Allowable Costs/Cost Principles) FALN Number 93.778 Alameda Health Care Services Agency - Medical Assistance Program (Medi-Cal Administrative Activities), Award Number MAA MOU 2022-2023, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.403(h) stated that a non-federal entity may charge only
allowable costs incurred during the approved budget period of a federal award’s period of performance.
Condition/Context: As a result of our audit procedures, we noted 1 of 40 timesheets tested in which the hours on
the employee’s timesheet did not agree to the hours reported on the time study. We identified 2.5 hours of
steward leave being reported on the timesheet but not the time study.
Repeat Finding from Prior Year(s): No
Cause and Effect: The Health System did not have proper controls in place to ensure hours reported on the
timesheet agree to the hours on the time study, which could lead to inaccurate hours being reported and
disbursed to employees.
Questioned Cost: None
Recommendation: We recommend management review policies and procedures to ensure the hours reported
on the timesheet agree to the hours on the time study.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that costs incurred are appropriately charged based on the contracts’
performance periods.
Finding Number 2023-003: Reporting (Significant Deficiency over Internal Control and Instances of
Noncompliance – Reporting) FALN Number 93.224 Health Center Program (Community Health Centers, Migrant Health Centers, Health care for the Homeless, and Public Housing Primary Care), Award Number MAA MOU 2022-2023, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must establish
and maintain effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations and terms and
conditions of the federal award.
Condition/Context: As a result of our audit procedures over the yearly reports, we noted the Uniform Data
System (UDS) Clinical Measures Report and Financial Report did not have evidence of management’s review
prior to report submission.
Repeat Finding from Prior Year(s): No
Cause and Effect: The Health System did not have proper controls in place to ensure the yearly reports are
prepared and reviewed by separate individuals with evidence of review documented and retained, which could
lead to inaccurate information being reported.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to ensure the yearly
reports, UDS Clinical Measures Report and Financial Report, are prepared and reviewed by separate individuals
with evidence of review documented prior to submission.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that performance reports are prepared and reviewed by separate
individuals. Documentation will be maintained by the program to evidence preparation and review processes and
timely filing of annual report.
Finding Number 2023-004: Contract Requirements - Earmarking (Significant Deficiency over Internal
Control and Instances of Noncompliance over Major Federal Program – Matching, Level of Effort and
Earmarking) FALN Number 93.959 Block Grants for Prevention and Treatment of Substance Abuse, Award Number 900077, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must establish
and maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and
conditions of the federal award.
Condition/Context: As a result of our audit procedures, we noted management did not have evidence retained to
support its compliance with the program’s earmarking requirements related to process objectives, quality
objectives and impact objectives.
Repeat Finding from Prior Year(s): No
Cause and Effect: The Health System did not have proper controls in place to ensure the fulfillment of the
earmarking requirements are properly documented, which led to non-compliance with program requirements.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to clearly identify the
earmarking requirements of the program and retain proper documentations to support how the requirements are
fulfilled.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will implement policies and procedures to ensure
earmarking requirements are completed and evidence of review documented
Finding Number 2023-005: Contract Requirement – Reporting (Significant Deficiency over Internal Control
and Instances of Noncompliance – Reporting) FALN Number 93.959 Block Grants for Prevention and Treatment of Substance Abuse, Award Number 900077, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must establish
and maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and
conditions of the federal award.
Condition/Context: As a result of our audit procedures, we noted management did not have evidence to support
its compliance with the program contract’s Third-Quarter Financial Report and the Quarterly Program Report
requirements.
Repeat Finding from Prior Year(s): No
Cause and Effect: The Health System did not have proper controls in place to ensure the required reports are
properly prepared, reviewed and submitted timely.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to clearly identify all
reporting requirements of the program to ensure all reports are prepared accurately and submitted timely.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that required reports are prepared and reviewed by separate individuals.
Documentation will be maintained by the program to evidence preparation and review processes and timely filing
of required reports.
Finding Number 2023-006: Costs Incurred Outside Period of Performance (Significant Deficiency over
Internal Control and Instances of Noncompliance – Period of Performance; Allowable Costs/Cost
Principles) FALN Number 93.959 Block Grants for Prevention and Treatment of Substance Abuse, Award Number 900077, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.403(h) stated that a non-federal entity may charge only
allowable costs incurred during the approved budget period of a federal award’s period of performance.
Condition/Context: As a result of our audit procedures, we noted 2 of 25 timesheets tested in which the costs
incurred were charged outside of the program’s performance period. The two timesheets had payroll costs
incurred during the pay period of 6/12/2022 – 6/25/2022; however, the contract had a performance period of
7/1/2022 – 6/30/2023.
Repeat Finding from Prior Year(s): No
Cause and Effect: The Health System did not have proper controls in place to ensure only costs incurred in the
performance period were charged to the program, which resulted in non-compliance with program requirements.
Questioned Cost: None
Recommendation: We recommend management review policies and procedures of the program to ensure the
costs incurred are appropriately charged based on the contracts’ performance periods.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that costs incurred are appropriately charged based on the contracts’
performance periods.
Finding Number 2023-007: Costs Incurred Outside Period of Performance (Significant Deficiency over
Internal Control and Instances of Noncompliance – Period of Performance; Allowable Costs/Cost
Principles) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance, Award Number 94-3302014, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.403(h) stated that a non-federal entity may charge only
allowable costs incurred during the approved budget period of a federal award’s period of performance.
Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings,
we noted 1 sample of payroll expenditure of $6,561 incurred during the pay period 3/19/2023 – 4/1/2023;
however, the payroll costs incurred was charged to the program based on the pay date instead of the pay period
incurred.
Repeat Finding from Prior Year(s): Yes, Finding Number 2022-003
Cause and Effect: The Health System did not have proper controls in place to ensure only costs incurred in the
period of performance were charged to the program, which resulted in costs outside of period of performance
being charged to the program.
Questioned Cost: None
Recommendation: We recommend management review policies and procedures of the program to ensure the
costs incurred are appropriately charged based on the contracts’ performance periods.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that costs incurred are appropriately charged based on the contracts’
performance periods.
Finding Number 2023-008: Duplicate Charges (Significant Deficiency over Internal Control and Instances
of Noncompliance – Allowable Costs/Cost Principles) FALN Number 16.575 U.S. Department of Justice, Office
of Victims of Crime – Crime Victim Assistance, Award Number 94-3302014, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must establish
and maintain effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and
conditions of the federal award.
Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings,
we noted 1 sample of a $2,444 non-payroll expenditure had been duplicated on invoices remitted to the grantor.
Repeat Finding from Prior Year(s): Yes, Finding Number 2022-004
Cause and Effect: The Health System did not have proper controls in place to prevent duplicate transactions
from being entered into the system and charged to the program, which resulted in duplicate costs being charged
to the program.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to prevent duplicate
transactions from being charged to the program.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to prevent duplicate transactions from being charged to the program.
Finding Number 2023-009: Costs Incurred & Paid Prior to Reimbursements (Significant Deficiency over
Internal Control and Instance of Noncompliance – Cash Management; Period of Performance) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance, Award Number 94-3302014, Award Year 2022-2023
Criteria: 2023 Compliance Supplement stated that program costs must be paid by non-federal entity funds before
submitting a payment request (2 CFR section 200.305(b)(3)) (i.e., the non-federal entity must disburse funds for
program purposes before requesting payment from the federal awarding agency or pass-through entity). In
addition, a non-federal entity may charge only allowable costs incurred during the approved budget period of a
federal award’s period of performance.
Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings,
we noted 1 sample of $1,000 nonpayroll expenditures that was submitted for reimbursement prior to the
expenditure being incurred.
Repeat Finding from Prior Year(s): Yes, Finding Number 2022-007
Cause and Effect: The Health System did not have proper controls in place to ensure expenditures are incurred
and paid for prior to reimbursements, and that expenditures are incurred within the period of performance of the
contract, which resulted in noncompliance with the compliance requirements of the program.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to ensure funds are
disbursed for expenditures incurred prior to reimbursement requests, and that expenditures are incurred within
the contract’s performance period.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure funds are disbursed for expenditures incurred prior to requesting
reimbursement and that expenditures are incurred within the contract’s performance period.
Finding Number 2023-010: Reporting (Significant Deficiency over Internal Control and Instances of
Noncompliance – Reporting) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance, Award Number 94-3302014, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must establish
and maintain effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations and terms and
conditions of the federal award.
Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings,
we noted 1 sample of untimely financial reporting submitting to the grantor. The financial report was for the
quarter ended 3/31/2023 with a due date of 30 days after the reporting period; however, the report was submitted
on 6/13/2023. We also noted 1 sample of performance report for the quarter ended 3/31/2023 that did not have
clear evidence of preparer and reviewer of the report.
Repeat Finding from Prior Year(s): Yes, Finding Number 2022-008
Cause and Effect: The Health System did not have proper controls in place to ensure the performance reports
are prepared and reviewed by separate individuals with evidence of review documented and retained, which
could lead to inaccurate information being reported. In addition, the Health System did not have proper controls in
place to ensure financial reports are submitted timely with underlying support properly documented, which
resulted in untimely reporting filing.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to ensure performance
reports are prepared and reviewed by separate individuals with evidence of review documented and that financial
reports are submitted timely with underlying support properly documented.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that required reports are prepared and reviewed by separate individuals.
Documentation will be maintained by the program to evidence preparation and review processes and timely filing
of required reports.
Finding Number 2023-002: Timesheet vs. Time Study Hours (Significant Deficiency over Internal Control
and Instance of Noncompliance – Allowable Costs/Cost Principles) FALN Number 93.778 Alameda Health Care Services Agency - Medical Assistance Program (Medi-Cal Administrative Activities), Award Number MAA MOU 2022-2023, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.403(h) stated that a non-federal entity may charge only
allowable costs incurred during the approved budget period of a federal award’s period of performance.
Condition/Context: As a result of our audit procedures, we noted 1 of 40 timesheets tested in which the hours on
the employee’s timesheet did not agree to the hours reported on the time study. We identified 2.5 hours of
steward leave being reported on the timesheet but not the time study.
Repeat Finding from Prior Year(s): No
Cause and Effect: The Health System did not have proper controls in place to ensure hours reported on the
timesheet agree to the hours on the time study, which could lead to inaccurate hours being reported and
disbursed to employees.
Questioned Cost: None
Recommendation: We recommend management review policies and procedures to ensure the hours reported
on the timesheet agree to the hours on the time study.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that costs incurred are appropriately charged based on the contracts’
performance periods.
Finding Number 2023-003: Reporting (Significant Deficiency over Internal Control and Instances of
Noncompliance – Reporting) FALN Number 93.224 Health Center Program (Community Health Centers, Migrant Health Centers, Health care for the Homeless, and Public Housing Primary Care), Award Number MAA MOU 2022-2023, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must establish
and maintain effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations and terms and
conditions of the federal award.
Condition/Context: As a result of our audit procedures over the yearly reports, we noted the Uniform Data
System (UDS) Clinical Measures Report and Financial Report did not have evidence of management’s review
prior to report submission.
Repeat Finding from Prior Year(s): No
Cause and Effect: The Health System did not have proper controls in place to ensure the yearly reports are
prepared and reviewed by separate individuals with evidence of review documented and retained, which could
lead to inaccurate information being reported.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to ensure the yearly
reports, UDS Clinical Measures Report and Financial Report, are prepared and reviewed by separate individuals
with evidence of review documented prior to submission.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that performance reports are prepared and reviewed by separate
individuals. Documentation will be maintained by the program to evidence preparation and review processes and
timely filing of annual report.
Finding Number 2023-004: Contract Requirements - Earmarking (Significant Deficiency over Internal
Control and Instances of Noncompliance over Major Federal Program – Matching, Level of Effort and
Earmarking) FALN Number 93.959 Block Grants for Prevention and Treatment of Substance Abuse, Award Number 900077, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must establish
and maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and
conditions of the federal award.
Condition/Context: As a result of our audit procedures, we noted management did not have evidence retained to
support its compliance with the program’s earmarking requirements related to process objectives, quality
objectives and impact objectives.
Repeat Finding from Prior Year(s): No
Cause and Effect: The Health System did not have proper controls in place to ensure the fulfillment of the
earmarking requirements are properly documented, which led to non-compliance with program requirements.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to clearly identify the
earmarking requirements of the program and retain proper documentations to support how the requirements are
fulfilled.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will implement policies and procedures to ensure
earmarking requirements are completed and evidence of review documented
Finding Number 2023-005: Contract Requirement – Reporting (Significant Deficiency over Internal Control
and Instances of Noncompliance – Reporting) FALN Number 93.959 Block Grants for Prevention and Treatment of Substance Abuse, Award Number 900077, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must establish
and maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and
conditions of the federal award.
Condition/Context: As a result of our audit procedures, we noted management did not have evidence to support
its compliance with the program contract’s Third-Quarter Financial Report and the Quarterly Program Report
requirements.
Repeat Finding from Prior Year(s): No
Cause and Effect: The Health System did not have proper controls in place to ensure the required reports are
properly prepared, reviewed and submitted timely.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to clearly identify all
reporting requirements of the program to ensure all reports are prepared accurately and submitted timely.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that required reports are prepared and reviewed by separate individuals.
Documentation will be maintained by the program to evidence preparation and review processes and timely filing
of required reports.
Finding Number 2023-006: Costs Incurred Outside Period of Performance (Significant Deficiency over
Internal Control and Instances of Noncompliance – Period of Performance; Allowable Costs/Cost
Principles) FALN Number 93.959 Block Grants for Prevention and Treatment of Substance Abuse, Award Number 900077, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.403(h) stated that a non-federal entity may charge only
allowable costs incurred during the approved budget period of a federal award’s period of performance.
Condition/Context: As a result of our audit procedures, we noted 2 of 25 timesheets tested in which the costs
incurred were charged outside of the program’s performance period. The two timesheets had payroll costs
incurred during the pay period of 6/12/2022 – 6/25/2022; however, the contract had a performance period of
7/1/2022 – 6/30/2023.
Repeat Finding from Prior Year(s): No
Cause and Effect: The Health System did not have proper controls in place to ensure only costs incurred in the
performance period were charged to the program, which resulted in non-compliance with program requirements.
Questioned Cost: None
Recommendation: We recommend management review policies and procedures of the program to ensure the
costs incurred are appropriately charged based on the contracts’ performance periods.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that costs incurred are appropriately charged based on the contracts’
performance periods.
Finding Number 2023-007: Costs Incurred Outside Period of Performance (Significant Deficiency over
Internal Control and Instances of Noncompliance – Period of Performance; Allowable Costs/Cost
Principles) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance, Award Number 94-3302014, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.403(h) stated that a non-federal entity may charge only
allowable costs incurred during the approved budget period of a federal award’s period of performance.
Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings,
we noted 1 sample of payroll expenditure of $6,561 incurred during the pay period 3/19/2023 – 4/1/2023;
however, the payroll costs incurred was charged to the program based on the pay date instead of the pay period
incurred.
Repeat Finding from Prior Year(s): Yes, Finding Number 2022-003
Cause and Effect: The Health System did not have proper controls in place to ensure only costs incurred in the
period of performance were charged to the program, which resulted in costs outside of period of performance
being charged to the program.
Questioned Cost: None
Recommendation: We recommend management review policies and procedures of the program to ensure the
costs incurred are appropriately charged based on the contracts’ performance periods.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that costs incurred are appropriately charged based on the contracts’
performance periods.
Finding Number 2023-008: Duplicate Charges (Significant Deficiency over Internal Control and Instances
of Noncompliance – Allowable Costs/Cost Principles) FALN Number 16.575 U.S. Department of Justice, Office
of Victims of Crime – Crime Victim Assistance, Award Number 94-3302014, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must establish
and maintain effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and
conditions of the federal award.
Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings,
we noted 1 sample of a $2,444 non-payroll expenditure had been duplicated on invoices remitted to the grantor.
Repeat Finding from Prior Year(s): Yes, Finding Number 2022-004
Cause and Effect: The Health System did not have proper controls in place to prevent duplicate transactions
from being entered into the system and charged to the program, which resulted in duplicate costs being charged
to the program.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to prevent duplicate
transactions from being charged to the program.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to prevent duplicate transactions from being charged to the program.
Finding Number 2023-009: Costs Incurred & Paid Prior to Reimbursements (Significant Deficiency over
Internal Control and Instance of Noncompliance – Cash Management; Period of Performance) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance, Award Number 94-3302014, Award Year 2022-2023
Criteria: 2023 Compliance Supplement stated that program costs must be paid by non-federal entity funds before
submitting a payment request (2 CFR section 200.305(b)(3)) (i.e., the non-federal entity must disburse funds for
program purposes before requesting payment from the federal awarding agency or pass-through entity). In
addition, a non-federal entity may charge only allowable costs incurred during the approved budget period of a
federal award’s period of performance.
Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings,
we noted 1 sample of $1,000 nonpayroll expenditures that was submitted for reimbursement prior to the
expenditure being incurred.
Repeat Finding from Prior Year(s): Yes, Finding Number 2022-007
Cause and Effect: The Health System did not have proper controls in place to ensure expenditures are incurred
and paid for prior to reimbursements, and that expenditures are incurred within the period of performance of the
contract, which resulted in noncompliance with the compliance requirements of the program.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to ensure funds are
disbursed for expenditures incurred prior to reimbursement requests, and that expenditures are incurred within
the contract’s performance period.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure funds are disbursed for expenditures incurred prior to requesting
reimbursement and that expenditures are incurred within the contract’s performance period.
Finding Number 2023-010: Reporting (Significant Deficiency over Internal Control and Instances of
Noncompliance – Reporting) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance, Award Number 94-3302014, Award Year 2022-2023
Criteria: 2023 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must establish
and maintain effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations and terms and
conditions of the federal award.
Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings,
we noted 1 sample of untimely financial reporting submitting to the grantor. The financial report was for the
quarter ended 3/31/2023 with a due date of 30 days after the reporting period; however, the report was submitted
on 6/13/2023. We also noted 1 sample of performance report for the quarter ended 3/31/2023 that did not have
clear evidence of preparer and reviewer of the report.
Repeat Finding from Prior Year(s): Yes, Finding Number 2022-008
Cause and Effect: The Health System did not have proper controls in place to ensure the performance reports
are prepared and reviewed by separate individuals with evidence of review documented and retained, which
could lead to inaccurate information being reported. In addition, the Health System did not have proper controls in
place to ensure financial reports are submitted timely with underlying support properly documented, which
resulted in untimely reporting filing.
Questioned Cost: None
Recommendation: We recommend management implement policies and procedures to ensure performance
reports are prepared and reviewed by separate individuals with evidence of review documented and that financial
reports are submitted timely with underlying support properly documented.
Views of Responsible Officials and Planned Corrective Action:
Management agrees with the finding. The Health System will review, modify, and implement policies and
procedures over the program to ensure that required reports are prepared and reviewed by separate individuals.
Documentation will be maintained by the program to evidence preparation and review processes and timely filing
of required reports.