2023-002 – Cash Management
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.305(b)(3) indicates reimbursement of costs previously occurred is an acceptable method for requesting payment of Federal funds. However, the Organization is responsible for determining that the entity paid for the costs for which reimbursement is being requested, prior to the date of the reimbursement request.
Condition: The Organization could not provide documentation to support that the draw down request was prepared by someone independent of the person who reviewed the request.
Questioned Costs: None.
Context: For six of six drawdowns selected for testing, CLA was able to obtain documentation of approval prior to draw down, but there was no documentation to support segregation of duties in the draw down process.
Cause: Management turnover.
Effect: Lack of segregation of duties could result in inaccurate amounts being drawn down.
Repeat Finding: No.
Recommendation: CLA recommends that the Organization maintain documentation of the individual preparing the draw down request, along documentation of an independent review being performed prior to the drawdown. This can be in the form of sign off, email, checklist, etc.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-002 – Cash Management
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.305(b)(3) indicates reimbursement of costs previously occurred is an acceptable method for requesting payment of Federal funds. However, the Organization is responsible for determining that the entity paid for the costs for which reimbursement is being requested, prior to the date of the reimbursement request.
Condition: The Organization could not provide documentation to support that the draw down request was prepared by someone independent of the person who reviewed the request.
Questioned Costs: None.
Context: For six of six drawdowns selected for testing, CLA was able to obtain documentation of approval prior to draw down, but there was no documentation to support segregation of duties in the draw down process.
Cause: Management turnover.
Effect: Lack of segregation of duties could result in inaccurate amounts being drawn down.
Repeat Finding: No.
Recommendation: CLA recommends that the Organization maintain documentation of the individual preparing the draw down request, along documentation of an independent review being performed prior to the drawdown. This can be in the form of sign off, email, checklist, etc.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-002 – Cash Management
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.305(b)(3) indicates reimbursement of costs previously occurred is an acceptable method for requesting payment of Federal funds. However, the Organization is responsible for determining that the entity paid for the costs for which reimbursement is being requested, prior to the date of the reimbursement request.
Condition: The Organization could not provide documentation to support that the draw down request was prepared by someone independent of the person who reviewed the request.
Questioned Costs: None.
Context: For six of six drawdowns selected for testing, CLA was able to obtain documentation of approval prior to draw down, but there was no documentation to support segregation of duties in the draw down process.
Cause: Management turnover.
Effect: Lack of segregation of duties could result in inaccurate amounts being drawn down.
Repeat Finding: No.
Recommendation: CLA recommends that the Organization maintain documentation of the individual preparing the draw down request, along documentation of an independent review being performed prior to the drawdown. This can be in the form of sign off, email, checklist, etc.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-002 – Cash Management
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.305(b)(3) indicates reimbursement of costs previously occurred is an acceptable method for requesting payment of Federal funds. However, the Organization is responsible for determining that the entity paid for the costs for which reimbursement is being requested, prior to the date of the reimbursement request.
Condition: The Organization could not provide documentation to support that the draw down request was prepared by someone independent of the person who reviewed the request.
Questioned Costs: None.
Context: For six of six drawdowns selected for testing, CLA was able to obtain documentation of approval prior to draw down, but there was no documentation to support segregation of duties in the draw down process.
Cause: Management turnover.
Effect: Lack of segregation of duties could result in inaccurate amounts being drawn down.
Repeat Finding: No.
Recommendation: CLA recommends that the Organization maintain documentation of the individual preparing the draw down request, along documentation of an independent review being performed prior to the drawdown. This can be in the form of sign off, email, checklist, etc.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-003 – Allowable Costs
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: Two employees' wages for the pay periods selected for testing were charged in excess of 100% to the various federal and non-federal grants. One employee was charged 115% and the other 120%.
Questioned Costs: $588.
Context: Of the 37 payroll transactions selected for testing, two employees' wages were charged in excess of 100% to the various federal and non-federal grants.
Cause: Oversight.
Effect: Employees' wages are charged in excess of actual expenses incurred.
Repeat Finding: No.
Recommendation: CLA recommends the Organization maintain a master file where employees' who are charged in excess to the grant can be easily identified, or the Organization implement grant tracking within its payroll system to ensure no employee's wages are charged greater than 100%.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-003 – Allowable Costs
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: Two employees' wages for the pay periods selected for testing were charged in excess of 100% to the various federal and non-federal grants. One employee was charged 115% and the other 120%.
Questioned Costs: $588.
Context: Of the 37 payroll transactions selected for testing, two employees' wages were charged in excess of 100% to the various federal and non-federal grants.
Cause: Oversight.
Effect: Employees' wages are charged in excess of actual expenses incurred.
Repeat Finding: No.
Recommendation: CLA recommends the Organization maintain a master file where employees' who are charged in excess to the grant can be easily identified, or the Organization implement grant tracking within its payroll system to ensure no employee's wages are charged greater than 100%.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-003 – Allowable Costs
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: Two employees' wages for the pay periods selected for testing were charged in excess of 100% to the various federal and non-federal grants. One employee was charged 115% and the other 120%.
Questioned Costs: $588.
Context: Of the 37 payroll transactions selected for testing, two employees' wages were charged in excess of 100% to the various federal and non-federal grants.
Cause: Oversight.
Effect: Employees' wages are charged in excess of actual expenses incurred.
Repeat Finding: No.
Recommendation: CLA recommends the Organization maintain a master file where employees' who are charged in excess to the grant can be easily identified, or the Organization implement grant tracking within its payroll system to ensure no employee's wages are charged greater than 100%.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-004 – Procurement
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.320 Methods of procurement to be followed: The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the approved procurement methods used for the acquisition of property or services required under a Federal award or sub-award.
Condition: The Organization did not have a procurement policy in place which was consistent with the requirements of the Uniform Guidance. As a result, the organization could not provide supporting documentation showing that engaged vendors had gone through an appropriate procurement process.
Questioned Costs: $50,649 .
Context: Five of five vendors selected for procurement testing did not have documentation showing that the cost had been procured in accordance with the Uniform Guidance.
Cause: Management turnover.
Effect: Lack of appropriate procurement policies could result in the Organization engaging vendors who are not the most efficient or economical.
Repeat Finding: Yes, 2022-004.
Recommendation: We recommend the Organization revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-004 – Procurement
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.320 Methods of procurement to be followed: The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the approved procurement methods used for the acquisition of property or services required under a Federal award or sub-award.
Condition: The Organization did not have a procurement policy in place which was consistent with the requirements of the Uniform Guidance. As a result, the organization could not provide supporting documentation showing that engaged vendors had gone through an appropriate procurement process.
Questioned Costs: $50,649 .
Context: Five of five vendors selected for procurement testing did not have documentation showing that the cost had been procured in accordance with the Uniform Guidance.
Cause: Management turnover.
Effect: Lack of appropriate procurement policies could result in the Organization engaging vendors who are not the most efficient or economical.
Repeat Finding: Yes, 2022-004.
Recommendation: We recommend the Organization revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-005 – Suspension and Debarment
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.214 Suspension and debarment. Non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities.
Condition: The Organization could not provide documentation that vendor was verified as not being suspended or debarred prior to entering into the transaction.
Questioned Costs: $48,472.
Context: One of one vendor selected for testing suspension and debarment did not have documentation showing that suspension and debarment had been checked prior to entering into a contract.
Cause: Management turnover.
Effect: The Organization could enter into transactions using federal dollars with vendors that are suspended or debarred.
Repeat Finding: Yes, 2022-005.
Recommendation: We recommend that the Organization verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-006 – Allowable Costs
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Significant deficiency in internal control over compliance
Criteria or Specific
Requirement: § 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: The Organization could not provide supporting documentation showing management's review and approval of costs totaling $511 for camera supplies.
Questioned Costs: None.
Context: Of the three transactions selected for testing, there was no documentation available to support management's review and approval of one transaction.
Cause: Management turnover.
Effect: If costs are not reviewed and approved as being allowable, it could result in unallowable costs being charged to federal grants.
Repeat Finding: No.
Recommendation: We recommend the Organization maintain approvals electronically within Intacct.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-007 – Reporting
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Significant Deficiency in internal control over compliance
Criteria or Specific
Requirement: § 200.329 indicates that the non-federal entity is responsible for oversight of the operations of the Federal award supported activities. The non-Federal entity must monitor its activities under Federal awards to assure compliance with applicable Federal requirements and performance expectations are being achieved.
Condition: The Organization did not maintain supporting documentation showing an independent review and approval of Federal Financial Reports occurring prior to the reports being filed.
Questioned Costs: None.
Context: Two of two reports selected for testing did not contain evidence of an independent review occurring prior to the report being filed.
Cause: Management turnover.
Effect: Incorrect or inaccurate reports could be submitted if they are not reviewed prior to being filed.
Repeat Finding: No.
Recommendation: The Organization should ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-007 – Reporting
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Significant Deficiency in internal control over compliance
Criteria or Specific
Requirement: § 200.329 indicates that the non-federal entity is responsible for oversight of the operations of the Federal award supported activities. The non-Federal entity must monitor its activities under Federal awards to assure compliance with applicable Federal requirements and performance expectations are being achieved.
Condition: The Organization did not maintain supporting documentation showing an independent review and approval of Federal Financial Reports occurring prior to the reports being filed.
Questioned Costs: None.
Context: Two of two reports selected for testing did not contain evidence of an independent review occurring prior to the report being filed.
Cause: Management turnover.
Effect: Incorrect or inaccurate reports could be submitted if they are not reviewed prior to being filed.
Repeat Finding: No.
Recommendation: The Organization should ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-007 – Reporting
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Significant Deficiency in internal control over compliance
Criteria or Specific
Requirement: § 200.329 indicates that the non-federal entity is responsible for oversight of the operations of the Federal award supported activities. The non-Federal entity must monitor its activities under Federal awards to assure compliance with applicable Federal requirements and performance expectations are being achieved.
Condition: The Organization did not maintain supporting documentation showing an independent review and approval of Federal Financial Reports occurring prior to the reports being filed.
Questioned Costs: None.
Context: Two of two reports selected for testing did not contain evidence of an independent review occurring prior to the report being filed.
Cause: Management turnover.
Effect: Incorrect or inaccurate reports could be submitted if they are not reviewed prior to being filed.
Repeat Finding: No.
Recommendation: The Organization should ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-008 – Allowable Costs
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Immaterial Noncompliance and Significant Deficiency in internal control over compliance
Criteria or Specific
Requirement: Code of Federal Regulations (CFR) § 200.403(h) states that costs must be incurred during the approved budget period.
Condition: The Organization charged expenses incurred in fiscal year 2022 to the grant in fiscal year 2023.
Questioned Costs: $10,402.
Context: The Organization charged subscription costs for the period June 2022 - December 2022 to the grant in fiscal year 2023.
Cause: Management turnover.
Effect: The Organization is requesting reimbursement for costs not incurred during the fiscal year.
Repeat Finding: No.
Recommendation: We recommend that subscription costs spanning multiple fiscal years be tracked carefully and charged to the grant in the appropriate year.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-002 – Cash Management
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.305(b)(3) indicates reimbursement of costs previously occurred is an acceptable method for requesting payment of Federal funds. However, the Organization is responsible for determining that the entity paid for the costs for which reimbursement is being requested, prior to the date of the reimbursement request.
Condition: The Organization could not provide documentation to support that the draw down request was prepared by someone independent of the person who reviewed the request.
Questioned Costs: None.
Context: For six of six drawdowns selected for testing, CLA was able to obtain documentation of approval prior to draw down, but there was no documentation to support segregation of duties in the draw down process.
Cause: Management turnover.
Effect: Lack of segregation of duties could result in inaccurate amounts being drawn down.
Repeat Finding: No.
Recommendation: CLA recommends that the Organization maintain documentation of the individual preparing the draw down request, along documentation of an independent review being performed prior to the drawdown. This can be in the form of sign off, email, checklist, etc.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-002 – Cash Management
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.305(b)(3) indicates reimbursement of costs previously occurred is an acceptable method for requesting payment of Federal funds. However, the Organization is responsible for determining that the entity paid for the costs for which reimbursement is being requested, prior to the date of the reimbursement request.
Condition: The Organization could not provide documentation to support that the draw down request was prepared by someone independent of the person who reviewed the request.
Questioned Costs: None.
Context: For six of six drawdowns selected for testing, CLA was able to obtain documentation of approval prior to draw down, but there was no documentation to support segregation of duties in the draw down process.
Cause: Management turnover.
Effect: Lack of segregation of duties could result in inaccurate amounts being drawn down.
Repeat Finding: No.
Recommendation: CLA recommends that the Organization maintain documentation of the individual preparing the draw down request, along documentation of an independent review being performed prior to the drawdown. This can be in the form of sign off, email, checklist, etc.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-002 – Cash Management
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.305(b)(3) indicates reimbursement of costs previously occurred is an acceptable method for requesting payment of Federal funds. However, the Organization is responsible for determining that the entity paid for the costs for which reimbursement is being requested, prior to the date of the reimbursement request.
Condition: The Organization could not provide documentation to support that the draw down request was prepared by someone independent of the person who reviewed the request.
Questioned Costs: None.
Context: For six of six drawdowns selected for testing, CLA was able to obtain documentation of approval prior to draw down, but there was no documentation to support segregation of duties in the draw down process.
Cause: Management turnover.
Effect: Lack of segregation of duties could result in inaccurate amounts being drawn down.
Repeat Finding: No.
Recommendation: CLA recommends that the Organization maintain documentation of the individual preparing the draw down request, along documentation of an independent review being performed prior to the drawdown. This can be in the form of sign off, email, checklist, etc.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-002 – Cash Management
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.305(b)(3) indicates reimbursement of costs previously occurred is an acceptable method for requesting payment of Federal funds. However, the Organization is responsible for determining that the entity paid for the costs for which reimbursement is being requested, prior to the date of the reimbursement request.
Condition: The Organization could not provide documentation to support that the draw down request was prepared by someone independent of the person who reviewed the request.
Questioned Costs: None.
Context: For six of six drawdowns selected for testing, CLA was able to obtain documentation of approval prior to draw down, but there was no documentation to support segregation of duties in the draw down process.
Cause: Management turnover.
Effect: Lack of segregation of duties could result in inaccurate amounts being drawn down.
Repeat Finding: No.
Recommendation: CLA recommends that the Organization maintain documentation of the individual preparing the draw down request, along documentation of an independent review being performed prior to the drawdown. This can be in the form of sign off, email, checklist, etc.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-003 – Allowable Costs
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: Two employees' wages for the pay periods selected for testing were charged in excess of 100% to the various federal and non-federal grants. One employee was charged 115% and the other 120%.
Questioned Costs: $588.
Context: Of the 37 payroll transactions selected for testing, two employees' wages were charged in excess of 100% to the various federal and non-federal grants.
Cause: Oversight.
Effect: Employees' wages are charged in excess of actual expenses incurred.
Repeat Finding: No.
Recommendation: CLA recommends the Organization maintain a master file where employees' who are charged in excess to the grant can be easily identified, or the Organization implement grant tracking within its payroll system to ensure no employee's wages are charged greater than 100%.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-003 – Allowable Costs
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: Two employees' wages for the pay periods selected for testing were charged in excess of 100% to the various federal and non-federal grants. One employee was charged 115% and the other 120%.
Questioned Costs: $588.
Context: Of the 37 payroll transactions selected for testing, two employees' wages were charged in excess of 100% to the various federal and non-federal grants.
Cause: Oversight.
Effect: Employees' wages are charged in excess of actual expenses incurred.
Repeat Finding: No.
Recommendation: CLA recommends the Organization maintain a master file where employees' who are charged in excess to the grant can be easily identified, or the Organization implement grant tracking within its payroll system to ensure no employee's wages are charged greater than 100%.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-003 – Allowable Costs
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: Two employees' wages for the pay periods selected for testing were charged in excess of 100% to the various federal and non-federal grants. One employee was charged 115% and the other 120%.
Questioned Costs: $588.
Context: Of the 37 payroll transactions selected for testing, two employees' wages were charged in excess of 100% to the various federal and non-federal grants.
Cause: Oversight.
Effect: Employees' wages are charged in excess of actual expenses incurred.
Repeat Finding: No.
Recommendation: CLA recommends the Organization maintain a master file where employees' who are charged in excess to the grant can be easily identified, or the Organization implement grant tracking within its payroll system to ensure no employee's wages are charged greater than 100%.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-004 – Procurement
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.320 Methods of procurement to be followed: The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the approved procurement methods used for the acquisition of property or services required under a Federal award or sub-award.
Condition: The Organization did not have a procurement policy in place which was consistent with the requirements of the Uniform Guidance. As a result, the organization could not provide supporting documentation showing that engaged vendors had gone through an appropriate procurement process.
Questioned Costs: $50,649 .
Context: Five of five vendors selected for procurement testing did not have documentation showing that the cost had been procured in accordance with the Uniform Guidance.
Cause: Management turnover.
Effect: Lack of appropriate procurement policies could result in the Organization engaging vendors who are not the most efficient or economical.
Repeat Finding: Yes, 2022-004.
Recommendation: We recommend the Organization revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-004 – Procurement
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.320 Methods of procurement to be followed: The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the approved procurement methods used for the acquisition of property or services required under a Federal award or sub-award.
Condition: The Organization did not have a procurement policy in place which was consistent with the requirements of the Uniform Guidance. As a result, the organization could not provide supporting documentation showing that engaged vendors had gone through an appropriate procurement process.
Questioned Costs: $50,649 .
Context: Five of five vendors selected for procurement testing did not have documentation showing that the cost had been procured in accordance with the Uniform Guidance.
Cause: Management turnover.
Effect: Lack of appropriate procurement policies could result in the Organization engaging vendors who are not the most efficient or economical.
Repeat Finding: Yes, 2022-004.
Recommendation: We recommend the Organization revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-005 – Suspension and Debarment
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance
Criteria or Specific
Requirement: § 200.214 Suspension and debarment. Non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities.
Condition: The Organization could not provide documentation that vendor was verified as not being suspended or debarred prior to entering into the transaction.
Questioned Costs: $48,472.
Context: One of one vendor selected for testing suspension and debarment did not have documentation showing that suspension and debarment had been checked prior to entering into a contract.
Cause: Management turnover.
Effect: The Organization could enter into transactions using federal dollars with vendors that are suspended or debarred.
Repeat Finding: Yes, 2022-005.
Recommendation: We recommend that the Organization verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-006 – Allowable Costs
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Significant deficiency in internal control over compliance
Criteria or Specific
Requirement: § 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: The Organization could not provide supporting documentation showing management's review and approval of costs totaling $511 for camera supplies.
Questioned Costs: None.
Context: Of the three transactions selected for testing, there was no documentation available to support management's review and approval of one transaction.
Cause: Management turnover.
Effect: If costs are not reviewed and approved as being allowable, it could result in unallowable costs being charged to federal grants.
Repeat Finding: No.
Recommendation: We recommend the Organization maintain approvals electronically within Intacct.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-007 – Reporting
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Significant Deficiency in internal control over compliance
Criteria or Specific
Requirement: § 200.329 indicates that the non-federal entity is responsible for oversight of the operations of the Federal award supported activities. The non-Federal entity must monitor its activities under Federal awards to assure compliance with applicable Federal requirements and performance expectations are being achieved.
Condition: The Organization did not maintain supporting documentation showing an independent review and approval of Federal Financial Reports occurring prior to the reports being filed.
Questioned Costs: None.
Context: Two of two reports selected for testing did not contain evidence of an independent review occurring prior to the report being filed.
Cause: Management turnover.
Effect: Incorrect or inaccurate reports could be submitted if they are not reviewed prior to being filed.
Repeat Finding: No.
Recommendation: The Organization should ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-007 – Reporting
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Significant Deficiency in internal control over compliance
Criteria or Specific
Requirement: § 200.329 indicates that the non-federal entity is responsible for oversight of the operations of the Federal award supported activities. The non-Federal entity must monitor its activities under Federal awards to assure compliance with applicable Federal requirements and performance expectations are being achieved.
Condition: The Organization did not maintain supporting documentation showing an independent review and approval of Federal Financial Reports occurring prior to the reports being filed.
Questioned Costs: None.
Context: Two of two reports selected for testing did not contain evidence of an independent review occurring prior to the report being filed.
Cause: Management turnover.
Effect: Incorrect or inaccurate reports could be submitted if they are not reviewed prior to being filed.
Repeat Finding: No.
Recommendation: The Organization should ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-007 – Reporting
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Significant Deficiency in internal control over compliance
Criteria or Specific
Requirement: § 200.329 indicates that the non-federal entity is responsible for oversight of the operations of the Federal award supported activities. The non-Federal entity must monitor its activities under Federal awards to assure compliance with applicable Federal requirements and performance expectations are being achieved.
Condition: The Organization did not maintain supporting documentation showing an independent review and approval of Federal Financial Reports occurring prior to the reports being filed.
Questioned Costs: None.
Context: Two of two reports selected for testing did not contain evidence of an independent review occurring prior to the report being filed.
Cause: Management turnover.
Effect: Incorrect or inaccurate reports could be submitted if they are not reviewed prior to being filed.
Repeat Finding: No.
Recommendation: The Organization should ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed.
Views of Responsible
Officials: There is no disagreement with the audit finding.
2023-008 – Allowable Costs
Federal agency: U.S. Department of Health and Human Services
Federal program title: Health Centers Cluster
Assistance Listing Number: 93.224/93.527
Pass-Through Agency: n/a
Pass-Through Number(s): n/a
Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23
Type of Finding: Immaterial Noncompliance and Significant Deficiency in internal control over compliance
Criteria or Specific
Requirement: Code of Federal Regulations (CFR) § 200.403(h) states that costs must be incurred during the approved budget period.
Condition: The Organization charged expenses incurred in fiscal year 2022 to the grant in fiscal year 2023.
Questioned Costs: $10,402.
Context: The Organization charged subscription costs for the period June 2022 - December 2022 to the grant in fiscal year 2023.
Cause: Management turnover.
Effect: The Organization is requesting reimbursement for costs not incurred during the fiscal year.
Repeat Finding: No.
Recommendation: We recommend that subscription costs spanning multiple fiscal years be tracked carefully and charged to the grant in the appropriate year.
Views of Responsible
Officials: There is no disagreement with the audit finding.