FINDING 2022-003 – Cash Draw Downs and Internal Control over Cash Management
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Section 200.305, non-federal entities must minimize the time elapsing
between the transfer of funds from the federal agency or pass-through entity and disbursement by
the Center for program costs and proportionate share of allowable indirect costs. Additionally, 2 CFR
Section 200.302(b)(c) requires non-federal entities to establish written procedures to implement the
requirements 2 CFR Section 200.305. The Federal Acquisition Regulation clause at 48 CFR Section
52.2160-7(b)(1) requires that the non-federal entity request reimbursement for only allocable,
allowable, and reasonable contract costs that have already been paid or incurred.
Condition:
During our testing of draw requests, we noted certain draw requests were made prior to the related
costs being incurred. Although the funds were ultimately expended on items approved by the federal
award, they were not expended in a timely manner.
Cause:
The Center did not maintain detailed listings of eligible costs incurred at the time of the draw request
to support the amount requested in the Payment Management System. Additionally, the Center did
not maintain documentation of such review or approval that such costs were incurred prior to the draw
request, or the amount requested was in accordance with 2 CFR Section 200.305. Effect or Potential Effect:
Requests for draws per the Payment Management System may not have minimized the time elapsing
between payment by the federal agency or pass-through entity and disbursement by the Center and
the amounts drawn down may be inaccurate.
Questioned Costs:
None
Context:
We selected a sample of draw requests submitted through the Payment Management System during
the year ended September 30, 2022. The Center was unable to provide evidence of timely review
and approval of two requests out of 44, totaling $352,340.
Repeat Finding:
No
Recommendation:
We recommend the Center establish formal internal controls and documentation of its performance
relating to the determination of cash drawn downs and review and approval of drawn downs by
appropriate personnel who are knowledgeable of such requirements.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-004 – Excess Compensation
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
The Center is only allowed reimbursement for amounts that are approved in the award agreement.
These amounts are also below the limits set by HRSA as allowable compensation.
Condition:
During our testing of payroll, we noted the Center requested reimbursement for two individuals in
excess of amounts approved in the budget justification and in excess of the annual limit of $203,700
established by HRSA for the year ended September 30, 2022.
Cause:
The Center did not have a formal process in place to ensure that amounts requested for
reimbursement complied with the annual salary limitations required by HRSA. Effect or Potential Effect:
Costs charged to federal awards did not conform to the allowability of cost provisions in 2 CFR Part
200, Subpart E, or the award agreement.
Questioned Costs:
$30,259
Context:
We selected 40 payroll items submitted for reimbursement during the year ended September 30,
2022. Two of 40 items selected were in excess of the annual salary limitations.
Repeat Finding:
No
Recommendation:
We recommend that all payroll reimbursement requests be reviewed prior to submission to ensure
that all amounts requested are below amounts approved per the grant agreement, and below annual
limitations as set by HRSA
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-005 – Reporting
SIGNIFICANT DEFICIENCY, NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Part 200.303(a), the auditee must establish and maintain internal control
over the federal award that provides reasonable assurance that the auditee is managing the federal
award in compliance with federal statutes, regulations, and terms and conditions of the federal award.
Section 200.512 of the Uniform Guidance states that the audit, the data collection form, and the
reporting package must be submitted within 30 calendar days after the auditee receives the auditors’
report, or nine months after the end of the audit period (whichever is earlier).
Condition:
The Center did not complete its audit report prior to the required deadline.
Cause:
Due to a delay in the compiling of records related to the audit, the Center was not in compliance with
the reporting requirements.
Effect or Potential Effect:
The Center was not in compliance with the annual reporting of its data collection form.
Questioned Costs:
None
Repeat Finding:
No
Recommendation:
We recommend that the Center complete its audits and submit the required reports by the deadline.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-003 – Cash Draw Downs and Internal Control over Cash Management
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Section 200.305, non-federal entities must minimize the time elapsing
between the transfer of funds from the federal agency or pass-through entity and disbursement by
the Center for program costs and proportionate share of allowable indirect costs. Additionally, 2 CFR
Section 200.302(b)(c) requires non-federal entities to establish written procedures to implement the
requirements 2 CFR Section 200.305. The Federal Acquisition Regulation clause at 48 CFR Section
52.2160-7(b)(1) requires that the non-federal entity request reimbursement for only allocable,
allowable, and reasonable contract costs that have already been paid or incurred.
Condition:
During our testing of draw requests, we noted certain draw requests were made prior to the related
costs being incurred. Although the funds were ultimately expended on items approved by the federal
award, they were not expended in a timely manner.
Cause:
The Center did not maintain detailed listings of eligible costs incurred at the time of the draw request
to support the amount requested in the Payment Management System. Additionally, the Center did
not maintain documentation of such review or approval that such costs were incurred prior to the draw
request, or the amount requested was in accordance with 2 CFR Section 200.305. Effect or Potential Effect:
Requests for draws per the Payment Management System may not have minimized the time elapsing
between payment by the federal agency or pass-through entity and disbursement by the Center and
the amounts drawn down may be inaccurate.
Questioned Costs:
None
Context:
We selected a sample of draw requests submitted through the Payment Management System during
the year ended September 30, 2022. The Center was unable to provide evidence of timely review
and approval of two requests out of 44, totaling $352,340.
Repeat Finding:
No
Recommendation:
We recommend the Center establish formal internal controls and documentation of its performance
relating to the determination of cash drawn downs and review and approval of drawn downs by
appropriate personnel who are knowledgeable of such requirements.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-004 – Excess Compensation
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
The Center is only allowed reimbursement for amounts that are approved in the award agreement.
These amounts are also below the limits set by HRSA as allowable compensation.
Condition:
During our testing of payroll, we noted the Center requested reimbursement for two individuals in
excess of amounts approved in the budget justification and in excess of the annual limit of $203,700
established by HRSA for the year ended September 30, 2022.
Cause:
The Center did not have a formal process in place to ensure that amounts requested for
reimbursement complied with the annual salary limitations required by HRSA. Effect or Potential Effect:
Costs charged to federal awards did not conform to the allowability of cost provisions in 2 CFR Part
200, Subpart E, or the award agreement.
Questioned Costs:
$30,259
Context:
We selected 40 payroll items submitted for reimbursement during the year ended September 30,
2022. Two of 40 items selected were in excess of the annual salary limitations.
Repeat Finding:
No
Recommendation:
We recommend that all payroll reimbursement requests be reviewed prior to submission to ensure
that all amounts requested are below amounts approved per the grant agreement, and below annual
limitations as set by HRSA
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-005 – Reporting
SIGNIFICANT DEFICIENCY, NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Part 200.303(a), the auditee must establish and maintain internal control
over the federal award that provides reasonable assurance that the auditee is managing the federal
award in compliance with federal statutes, regulations, and terms and conditions of the federal award.
Section 200.512 of the Uniform Guidance states that the audit, the data collection form, and the
reporting package must be submitted within 30 calendar days after the auditee receives the auditors’
report, or nine months after the end of the audit period (whichever is earlier).
Condition:
The Center did not complete its audit report prior to the required deadline.
Cause:
Due to a delay in the compiling of records related to the audit, the Center was not in compliance with
the reporting requirements.
Effect or Potential Effect:
The Center was not in compliance with the annual reporting of its data collection form.
Questioned Costs:
None
Repeat Finding:
No
Recommendation:
We recommend that the Center complete its audits and submit the required reports by the deadline.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-003 – Cash Draw Downs and Internal Control over Cash Management
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Section 200.305, non-federal entities must minimize the time elapsing
between the transfer of funds from the federal agency or pass-through entity and disbursement by
the Center for program costs and proportionate share of allowable indirect costs. Additionally, 2 CFR
Section 200.302(b)(c) requires non-federal entities to establish written procedures to implement the
requirements 2 CFR Section 200.305. The Federal Acquisition Regulation clause at 48 CFR Section
52.2160-7(b)(1) requires that the non-federal entity request reimbursement for only allocable,
allowable, and reasonable contract costs that have already been paid or incurred.
Condition:
During our testing of draw requests, we noted certain draw requests were made prior to the related
costs being incurred. Although the funds were ultimately expended on items approved by the federal
award, they were not expended in a timely manner.
Cause:
The Center did not maintain detailed listings of eligible costs incurred at the time of the draw request
to support the amount requested in the Payment Management System. Additionally, the Center did
not maintain documentation of such review or approval that such costs were incurred prior to the draw
request, or the amount requested was in accordance with 2 CFR Section 200.305. Effect or Potential Effect:
Requests for draws per the Payment Management System may not have minimized the time elapsing
between payment by the federal agency or pass-through entity and disbursement by the Center and
the amounts drawn down may be inaccurate.
Questioned Costs:
None
Context:
We selected a sample of draw requests submitted through the Payment Management System during
the year ended September 30, 2022. The Center was unable to provide evidence of timely review
and approval of two requests out of 44, totaling $352,340.
Repeat Finding:
No
Recommendation:
We recommend the Center establish formal internal controls and documentation of its performance
relating to the determination of cash drawn downs and review and approval of drawn downs by
appropriate personnel who are knowledgeable of such requirements.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-004 – Excess Compensation
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
The Center is only allowed reimbursement for amounts that are approved in the award agreement.
These amounts are also below the limits set by HRSA as allowable compensation.
Condition:
During our testing of payroll, we noted the Center requested reimbursement for two individuals in
excess of amounts approved in the budget justification and in excess of the annual limit of $203,700
established by HRSA for the year ended September 30, 2022.
Cause:
The Center did not have a formal process in place to ensure that amounts requested for
reimbursement complied with the annual salary limitations required by HRSA. Effect or Potential Effect:
Costs charged to federal awards did not conform to the allowability of cost provisions in 2 CFR Part
200, Subpart E, or the award agreement.
Questioned Costs:
$30,259
Context:
We selected 40 payroll items submitted for reimbursement during the year ended September 30,
2022. Two of 40 items selected were in excess of the annual salary limitations.
Repeat Finding:
No
Recommendation:
We recommend that all payroll reimbursement requests be reviewed prior to submission to ensure
that all amounts requested are below amounts approved per the grant agreement, and below annual
limitations as set by HRSA
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-005 – Reporting
SIGNIFICANT DEFICIENCY, NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Part 200.303(a), the auditee must establish and maintain internal control
over the federal award that provides reasonable assurance that the auditee is managing the federal
award in compliance with federal statutes, regulations, and terms and conditions of the federal award.
Section 200.512 of the Uniform Guidance states that the audit, the data collection form, and the
reporting package must be submitted within 30 calendar days after the auditee receives the auditors’
report, or nine months after the end of the audit period (whichever is earlier).
Condition:
The Center did not complete its audit report prior to the required deadline.
Cause:
Due to a delay in the compiling of records related to the audit, the Center was not in compliance with
the reporting requirements.
Effect or Potential Effect:
The Center was not in compliance with the annual reporting of its data collection form.
Questioned Costs:
None
Repeat Finding:
No
Recommendation:
We recommend that the Center complete its audits and submit the required reports by the deadline.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-003 – Cash Draw Downs and Internal Control over Cash Management
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Section 200.305, non-federal entities must minimize the time elapsing
between the transfer of funds from the federal agency or pass-through entity and disbursement by
the Center for program costs and proportionate share of allowable indirect costs. Additionally, 2 CFR
Section 200.302(b)(c) requires non-federal entities to establish written procedures to implement the
requirements 2 CFR Section 200.305. The Federal Acquisition Regulation clause at 48 CFR Section
52.2160-7(b)(1) requires that the non-federal entity request reimbursement for only allocable,
allowable, and reasonable contract costs that have already been paid or incurred.
Condition:
During our testing of draw requests, we noted certain draw requests were made prior to the related
costs being incurred. Although the funds were ultimately expended on items approved by the federal
award, they were not expended in a timely manner.
Cause:
The Center did not maintain detailed listings of eligible costs incurred at the time of the draw request
to support the amount requested in the Payment Management System. Additionally, the Center did
not maintain documentation of such review or approval that such costs were incurred prior to the draw
request, or the amount requested was in accordance with 2 CFR Section 200.305. Effect or Potential Effect:
Requests for draws per the Payment Management System may not have minimized the time elapsing
between payment by the federal agency or pass-through entity and disbursement by the Center and
the amounts drawn down may be inaccurate.
Questioned Costs:
None
Context:
We selected a sample of draw requests submitted through the Payment Management System during
the year ended September 30, 2022. The Center was unable to provide evidence of timely review
and approval of two requests out of 44, totaling $352,340.
Repeat Finding:
No
Recommendation:
We recommend the Center establish formal internal controls and documentation of its performance
relating to the determination of cash drawn downs and review and approval of drawn downs by
appropriate personnel who are knowledgeable of such requirements.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-004 – Excess Compensation
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
The Center is only allowed reimbursement for amounts that are approved in the award agreement.
These amounts are also below the limits set by HRSA as allowable compensation.
Condition:
During our testing of payroll, we noted the Center requested reimbursement for two individuals in
excess of amounts approved in the budget justification and in excess of the annual limit of $203,700
established by HRSA for the year ended September 30, 2022.
Cause:
The Center did not have a formal process in place to ensure that amounts requested for
reimbursement complied with the annual salary limitations required by HRSA. Effect or Potential Effect:
Costs charged to federal awards did not conform to the allowability of cost provisions in 2 CFR Part
200, Subpart E, or the award agreement.
Questioned Costs:
$30,259
Context:
We selected 40 payroll items submitted for reimbursement during the year ended September 30,
2022. Two of 40 items selected were in excess of the annual salary limitations.
Repeat Finding:
No
Recommendation:
We recommend that all payroll reimbursement requests be reviewed prior to submission to ensure
that all amounts requested are below amounts approved per the grant agreement, and below annual
limitations as set by HRSA
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-005 – Reporting
SIGNIFICANT DEFICIENCY, NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Part 200.303(a), the auditee must establish and maintain internal control
over the federal award that provides reasonable assurance that the auditee is managing the federal
award in compliance with federal statutes, regulations, and terms and conditions of the federal award.
Section 200.512 of the Uniform Guidance states that the audit, the data collection form, and the
reporting package must be submitted within 30 calendar days after the auditee receives the auditors’
report, or nine months after the end of the audit period (whichever is earlier).
Condition:
The Center did not complete its audit report prior to the required deadline.
Cause:
Due to a delay in the compiling of records related to the audit, the Center was not in compliance with
the reporting requirements.
Effect or Potential Effect:
The Center was not in compliance with the annual reporting of its data collection form.
Questioned Costs:
None
Repeat Finding:
No
Recommendation:
We recommend that the Center complete its audits and submit the required reports by the deadline.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-003 – Cash Draw Downs and Internal Control over Cash Management
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Section 200.305, non-federal entities must minimize the time elapsing
between the transfer of funds from the federal agency or pass-through entity and disbursement by
the Center for program costs and proportionate share of allowable indirect costs. Additionally, 2 CFR
Section 200.302(b)(c) requires non-federal entities to establish written procedures to implement the
requirements 2 CFR Section 200.305. The Federal Acquisition Regulation clause at 48 CFR Section
52.2160-7(b)(1) requires that the non-federal entity request reimbursement for only allocable,
allowable, and reasonable contract costs that have already been paid or incurred.
Condition:
During our testing of draw requests, we noted certain draw requests were made prior to the related
costs being incurred. Although the funds were ultimately expended on items approved by the federal
award, they were not expended in a timely manner.
Cause:
The Center did not maintain detailed listings of eligible costs incurred at the time of the draw request
to support the amount requested in the Payment Management System. Additionally, the Center did
not maintain documentation of such review or approval that such costs were incurred prior to the draw
request, or the amount requested was in accordance with 2 CFR Section 200.305. Effect or Potential Effect:
Requests for draws per the Payment Management System may not have minimized the time elapsing
between payment by the federal agency or pass-through entity and disbursement by the Center and
the amounts drawn down may be inaccurate.
Questioned Costs:
None
Context:
We selected a sample of draw requests submitted through the Payment Management System during
the year ended September 30, 2022. The Center was unable to provide evidence of timely review
and approval of two requests out of 44, totaling $352,340.
Repeat Finding:
No
Recommendation:
We recommend the Center establish formal internal controls and documentation of its performance
relating to the determination of cash drawn downs and review and approval of drawn downs by
appropriate personnel who are knowledgeable of such requirements.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-004 – Excess Compensation
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
The Center is only allowed reimbursement for amounts that are approved in the award agreement.
These amounts are also below the limits set by HRSA as allowable compensation.
Condition:
During our testing of payroll, we noted the Center requested reimbursement for two individuals in
excess of amounts approved in the budget justification and in excess of the annual limit of $203,700
established by HRSA for the year ended September 30, 2022.
Cause:
The Center did not have a formal process in place to ensure that amounts requested for
reimbursement complied with the annual salary limitations required by HRSA. Effect or Potential Effect:
Costs charged to federal awards did not conform to the allowability of cost provisions in 2 CFR Part
200, Subpart E, or the award agreement.
Questioned Costs:
$30,259
Context:
We selected 40 payroll items submitted for reimbursement during the year ended September 30,
2022. Two of 40 items selected were in excess of the annual salary limitations.
Repeat Finding:
No
Recommendation:
We recommend that all payroll reimbursement requests be reviewed prior to submission to ensure
that all amounts requested are below amounts approved per the grant agreement, and below annual
limitations as set by HRSA
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-005 – Reporting
SIGNIFICANT DEFICIENCY, NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Part 200.303(a), the auditee must establish and maintain internal control
over the federal award that provides reasonable assurance that the auditee is managing the federal
award in compliance with federal statutes, regulations, and terms and conditions of the federal award.
Section 200.512 of the Uniform Guidance states that the audit, the data collection form, and the
reporting package must be submitted within 30 calendar days after the auditee receives the auditors’
report, or nine months after the end of the audit period (whichever is earlier).
Condition:
The Center did not complete its audit report prior to the required deadline.
Cause:
Due to a delay in the compiling of records related to the audit, the Center was not in compliance with
the reporting requirements.
Effect or Potential Effect:
The Center was not in compliance with the annual reporting of its data collection form.
Questioned Costs:
None
Repeat Finding:
No
Recommendation:
We recommend that the Center complete its audits and submit the required reports by the deadline.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-003 – Cash Draw Downs and Internal Control over Cash Management
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Section 200.305, non-federal entities must minimize the time elapsing
between the transfer of funds from the federal agency or pass-through entity and disbursement by
the Center for program costs and proportionate share of allowable indirect costs. Additionally, 2 CFR
Section 200.302(b)(c) requires non-federal entities to establish written procedures to implement the
requirements 2 CFR Section 200.305. The Federal Acquisition Regulation clause at 48 CFR Section
52.2160-7(b)(1) requires that the non-federal entity request reimbursement for only allocable,
allowable, and reasonable contract costs that have already been paid or incurred.
Condition:
During our testing of draw requests, we noted certain draw requests were made prior to the related
costs being incurred. Although the funds were ultimately expended on items approved by the federal
award, they were not expended in a timely manner.
Cause:
The Center did not maintain detailed listings of eligible costs incurred at the time of the draw request
to support the amount requested in the Payment Management System. Additionally, the Center did
not maintain documentation of such review or approval that such costs were incurred prior to the draw
request, or the amount requested was in accordance with 2 CFR Section 200.305. Effect or Potential Effect:
Requests for draws per the Payment Management System may not have minimized the time elapsing
between payment by the federal agency or pass-through entity and disbursement by the Center and
the amounts drawn down may be inaccurate.
Questioned Costs:
None
Context:
We selected a sample of draw requests submitted through the Payment Management System during
the year ended September 30, 2022. The Center was unable to provide evidence of timely review
and approval of two requests out of 44, totaling $352,340.
Repeat Finding:
No
Recommendation:
We recommend the Center establish formal internal controls and documentation of its performance
relating to the determination of cash drawn downs and review and approval of drawn downs by
appropriate personnel who are knowledgeable of such requirements.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-004 – Excess Compensation
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
The Center is only allowed reimbursement for amounts that are approved in the award agreement.
These amounts are also below the limits set by HRSA as allowable compensation.
Condition:
During our testing of payroll, we noted the Center requested reimbursement for two individuals in
excess of amounts approved in the budget justification and in excess of the annual limit of $203,700
established by HRSA for the year ended September 30, 2022.
Cause:
The Center did not have a formal process in place to ensure that amounts requested for
reimbursement complied with the annual salary limitations required by HRSA. Effect or Potential Effect:
Costs charged to federal awards did not conform to the allowability of cost provisions in 2 CFR Part
200, Subpart E, or the award agreement.
Questioned Costs:
$30,259
Context:
We selected 40 payroll items submitted for reimbursement during the year ended September 30,
2022. Two of 40 items selected were in excess of the annual salary limitations.
Repeat Finding:
No
Recommendation:
We recommend that all payroll reimbursement requests be reviewed prior to submission to ensure
that all amounts requested are below amounts approved per the grant agreement, and below annual
limitations as set by HRSA
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-005 – Reporting
SIGNIFICANT DEFICIENCY, NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Part 200.303(a), the auditee must establish and maintain internal control
over the federal award that provides reasonable assurance that the auditee is managing the federal
award in compliance with federal statutes, regulations, and terms and conditions of the federal award.
Section 200.512 of the Uniform Guidance states that the audit, the data collection form, and the
reporting package must be submitted within 30 calendar days after the auditee receives the auditors’
report, or nine months after the end of the audit period (whichever is earlier).
Condition:
The Center did not complete its audit report prior to the required deadline.
Cause:
Due to a delay in the compiling of records related to the audit, the Center was not in compliance with
the reporting requirements.
Effect or Potential Effect:
The Center was not in compliance with the annual reporting of its data collection form.
Questioned Costs:
None
Repeat Finding:
No
Recommendation:
We recommend that the Center complete its audits and submit the required reports by the deadline.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-003 – Cash Draw Downs and Internal Control over Cash Management
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Section 200.305, non-federal entities must minimize the time elapsing
between the transfer of funds from the federal agency or pass-through entity and disbursement by
the Center for program costs and proportionate share of allowable indirect costs. Additionally, 2 CFR
Section 200.302(b)(c) requires non-federal entities to establish written procedures to implement the
requirements 2 CFR Section 200.305. The Federal Acquisition Regulation clause at 48 CFR Section
52.2160-7(b)(1) requires that the non-federal entity request reimbursement for only allocable,
allowable, and reasonable contract costs that have already been paid or incurred.
Condition:
During our testing of draw requests, we noted certain draw requests were made prior to the related
costs being incurred. Although the funds were ultimately expended on items approved by the federal
award, they were not expended in a timely manner.
Cause:
The Center did not maintain detailed listings of eligible costs incurred at the time of the draw request
to support the amount requested in the Payment Management System. Additionally, the Center did
not maintain documentation of such review or approval that such costs were incurred prior to the draw
request, or the amount requested was in accordance with 2 CFR Section 200.305. Effect or Potential Effect:
Requests for draws per the Payment Management System may not have minimized the time elapsing
between payment by the federal agency or pass-through entity and disbursement by the Center and
the amounts drawn down may be inaccurate.
Questioned Costs:
None
Context:
We selected a sample of draw requests submitted through the Payment Management System during
the year ended September 30, 2022. The Center was unable to provide evidence of timely review
and approval of two requests out of 44, totaling $352,340.
Repeat Finding:
No
Recommendation:
We recommend the Center establish formal internal controls and documentation of its performance
relating to the determination of cash drawn downs and review and approval of drawn downs by
appropriate personnel who are knowledgeable of such requirements.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-004 – Excess Compensation
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
The Center is only allowed reimbursement for amounts that are approved in the award agreement.
These amounts are also below the limits set by HRSA as allowable compensation.
Condition:
During our testing of payroll, we noted the Center requested reimbursement for two individuals in
excess of amounts approved in the budget justification and in excess of the annual limit of $203,700
established by HRSA for the year ended September 30, 2022.
Cause:
The Center did not have a formal process in place to ensure that amounts requested for
reimbursement complied with the annual salary limitations required by HRSA. Effect or Potential Effect:
Costs charged to federal awards did not conform to the allowability of cost provisions in 2 CFR Part
200, Subpart E, or the award agreement.
Questioned Costs:
$30,259
Context:
We selected 40 payroll items submitted for reimbursement during the year ended September 30,
2022. Two of 40 items selected were in excess of the annual salary limitations.
Repeat Finding:
No
Recommendation:
We recommend that all payroll reimbursement requests be reviewed prior to submission to ensure
that all amounts requested are below amounts approved per the grant agreement, and below annual
limitations as set by HRSA
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-005 – Reporting
SIGNIFICANT DEFICIENCY, NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Part 200.303(a), the auditee must establish and maintain internal control
over the federal award that provides reasonable assurance that the auditee is managing the federal
award in compliance with federal statutes, regulations, and terms and conditions of the federal award.
Section 200.512 of the Uniform Guidance states that the audit, the data collection form, and the
reporting package must be submitted within 30 calendar days after the auditee receives the auditors’
report, or nine months after the end of the audit period (whichever is earlier).
Condition:
The Center did not complete its audit report prior to the required deadline.
Cause:
Due to a delay in the compiling of records related to the audit, the Center was not in compliance with
the reporting requirements.
Effect or Potential Effect:
The Center was not in compliance with the annual reporting of its data collection form.
Questioned Costs:
None
Repeat Finding:
No
Recommendation:
We recommend that the Center complete its audits and submit the required reports by the deadline.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-003 – Cash Draw Downs and Internal Control over Cash Management
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Section 200.305, non-federal entities must minimize the time elapsing
between the transfer of funds from the federal agency or pass-through entity and disbursement by
the Center for program costs and proportionate share of allowable indirect costs. Additionally, 2 CFR
Section 200.302(b)(c) requires non-federal entities to establish written procedures to implement the
requirements 2 CFR Section 200.305. The Federal Acquisition Regulation clause at 48 CFR Section
52.2160-7(b)(1) requires that the non-federal entity request reimbursement for only allocable,
allowable, and reasonable contract costs that have already been paid or incurred.
Condition:
During our testing of draw requests, we noted certain draw requests were made prior to the related
costs being incurred. Although the funds were ultimately expended on items approved by the federal
award, they were not expended in a timely manner.
Cause:
The Center did not maintain detailed listings of eligible costs incurred at the time of the draw request
to support the amount requested in the Payment Management System. Additionally, the Center did
not maintain documentation of such review or approval that such costs were incurred prior to the draw
request, or the amount requested was in accordance with 2 CFR Section 200.305. Effect or Potential Effect:
Requests for draws per the Payment Management System may not have minimized the time elapsing
between payment by the federal agency or pass-through entity and disbursement by the Center and
the amounts drawn down may be inaccurate.
Questioned Costs:
None
Context:
We selected a sample of draw requests submitted through the Payment Management System during
the year ended September 30, 2022. The Center was unable to provide evidence of timely review
and approval of two requests out of 44, totaling $352,340.
Repeat Finding:
No
Recommendation:
We recommend the Center establish formal internal controls and documentation of its performance
relating to the determination of cash drawn downs and review and approval of drawn downs by
appropriate personnel who are knowledgeable of such requirements.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-004 – Excess Compensation
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
The Center is only allowed reimbursement for amounts that are approved in the award agreement.
These amounts are also below the limits set by HRSA as allowable compensation.
Condition:
During our testing of payroll, we noted the Center requested reimbursement for two individuals in
excess of amounts approved in the budget justification and in excess of the annual limit of $203,700
established by HRSA for the year ended September 30, 2022.
Cause:
The Center did not have a formal process in place to ensure that amounts requested for
reimbursement complied with the annual salary limitations required by HRSA. Effect or Potential Effect:
Costs charged to federal awards did not conform to the allowability of cost provisions in 2 CFR Part
200, Subpart E, or the award agreement.
Questioned Costs:
$30,259
Context:
We selected 40 payroll items submitted for reimbursement during the year ended September 30,
2022. Two of 40 items selected were in excess of the annual salary limitations.
Repeat Finding:
No
Recommendation:
We recommend that all payroll reimbursement requests be reviewed prior to submission to ensure
that all amounts requested are below amounts approved per the grant agreement, and below annual
limitations as set by HRSA
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-005 – Reporting
SIGNIFICANT DEFICIENCY, NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Part 200.303(a), the auditee must establish and maintain internal control
over the federal award that provides reasonable assurance that the auditee is managing the federal
award in compliance with federal statutes, regulations, and terms and conditions of the federal award.
Section 200.512 of the Uniform Guidance states that the audit, the data collection form, and the
reporting package must be submitted within 30 calendar days after the auditee receives the auditors’
report, or nine months after the end of the audit period (whichever is earlier).
Condition:
The Center did not complete its audit report prior to the required deadline.
Cause:
Due to a delay in the compiling of records related to the audit, the Center was not in compliance with
the reporting requirements.
Effect or Potential Effect:
The Center was not in compliance with the annual reporting of its data collection form.
Questioned Costs:
None
Repeat Finding:
No
Recommendation:
We recommend that the Center complete its audits and submit the required reports by the deadline.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-003 – Cash Draw Downs and Internal Control over Cash Management
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Section 200.305, non-federal entities must minimize the time elapsing
between the transfer of funds from the federal agency or pass-through entity and disbursement by
the Center for program costs and proportionate share of allowable indirect costs. Additionally, 2 CFR
Section 200.302(b)(c) requires non-federal entities to establish written procedures to implement the
requirements 2 CFR Section 200.305. The Federal Acquisition Regulation clause at 48 CFR Section
52.2160-7(b)(1) requires that the non-federal entity request reimbursement for only allocable,
allowable, and reasonable contract costs that have already been paid or incurred.
Condition:
During our testing of draw requests, we noted certain draw requests were made prior to the related
costs being incurred. Although the funds were ultimately expended on items approved by the federal
award, they were not expended in a timely manner.
Cause:
The Center did not maintain detailed listings of eligible costs incurred at the time of the draw request
to support the amount requested in the Payment Management System. Additionally, the Center did
not maintain documentation of such review or approval that such costs were incurred prior to the draw
request, or the amount requested was in accordance with 2 CFR Section 200.305. Effect or Potential Effect:
Requests for draws per the Payment Management System may not have minimized the time elapsing
between payment by the federal agency or pass-through entity and disbursement by the Center and
the amounts drawn down may be inaccurate.
Questioned Costs:
None
Context:
We selected a sample of draw requests submitted through the Payment Management System during
the year ended September 30, 2022. The Center was unable to provide evidence of timely review
and approval of two requests out of 44, totaling $352,340.
Repeat Finding:
No
Recommendation:
We recommend the Center establish formal internal controls and documentation of its performance
relating to the determination of cash drawn downs and review and approval of drawn downs by
appropriate personnel who are knowledgeable of such requirements.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-004 – Excess Compensation
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
The Center is only allowed reimbursement for amounts that are approved in the award agreement.
These amounts are also below the limits set by HRSA as allowable compensation.
Condition:
During our testing of payroll, we noted the Center requested reimbursement for two individuals in
excess of amounts approved in the budget justification and in excess of the annual limit of $203,700
established by HRSA for the year ended September 30, 2022.
Cause:
The Center did not have a formal process in place to ensure that amounts requested for
reimbursement complied with the annual salary limitations required by HRSA. Effect or Potential Effect:
Costs charged to federal awards did not conform to the allowability of cost provisions in 2 CFR Part
200, Subpart E, or the award agreement.
Questioned Costs:
$30,259
Context:
We selected 40 payroll items submitted for reimbursement during the year ended September 30,
2022. Two of 40 items selected were in excess of the annual salary limitations.
Repeat Finding:
No
Recommendation:
We recommend that all payroll reimbursement requests be reviewed prior to submission to ensure
that all amounts requested are below amounts approved per the grant agreement, and below annual
limitations as set by HRSA
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-005 – Reporting
SIGNIFICANT DEFICIENCY, NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Part 200.303(a), the auditee must establish and maintain internal control
over the federal award that provides reasonable assurance that the auditee is managing the federal
award in compliance with federal statutes, regulations, and terms and conditions of the federal award.
Section 200.512 of the Uniform Guidance states that the audit, the data collection form, and the
reporting package must be submitted within 30 calendar days after the auditee receives the auditors’
report, or nine months after the end of the audit period (whichever is earlier).
Condition:
The Center did not complete its audit report prior to the required deadline.
Cause:
Due to a delay in the compiling of records related to the audit, the Center was not in compliance with
the reporting requirements.
Effect or Potential Effect:
The Center was not in compliance with the annual reporting of its data collection form.
Questioned Costs:
None
Repeat Finding:
No
Recommendation:
We recommend that the Center complete its audits and submit the required reports by the deadline.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-003 – Cash Draw Downs and Internal Control over Cash Management
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Section 200.305, non-federal entities must minimize the time elapsing
between the transfer of funds from the federal agency or pass-through entity and disbursement by
the Center for program costs and proportionate share of allowable indirect costs. Additionally, 2 CFR
Section 200.302(b)(c) requires non-federal entities to establish written procedures to implement the
requirements 2 CFR Section 200.305. The Federal Acquisition Regulation clause at 48 CFR Section
52.2160-7(b)(1) requires that the non-federal entity request reimbursement for only allocable,
allowable, and reasonable contract costs that have already been paid or incurred.
Condition:
During our testing of draw requests, we noted certain draw requests were made prior to the related
costs being incurred. Although the funds were ultimately expended on items approved by the federal
award, they were not expended in a timely manner.
Cause:
The Center did not maintain detailed listings of eligible costs incurred at the time of the draw request
to support the amount requested in the Payment Management System. Additionally, the Center did
not maintain documentation of such review or approval that such costs were incurred prior to the draw
request, or the amount requested was in accordance with 2 CFR Section 200.305. Effect or Potential Effect:
Requests for draws per the Payment Management System may not have minimized the time elapsing
between payment by the federal agency or pass-through entity and disbursement by the Center and
the amounts drawn down may be inaccurate.
Questioned Costs:
None
Context:
We selected a sample of draw requests submitted through the Payment Management System during
the year ended September 30, 2022. The Center was unable to provide evidence of timely review
and approval of two requests out of 44, totaling $352,340.
Repeat Finding:
No
Recommendation:
We recommend the Center establish formal internal controls and documentation of its performance
relating to the determination of cash drawn downs and review and approval of drawn downs by
appropriate personnel who are knowledgeable of such requirements.
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-004 – Excess Compensation
MATERIAL WEAKNESS, MATERIAL NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
The Center is only allowed reimbursement for amounts that are approved in the award agreement.
These amounts are also below the limits set by HRSA as allowable compensation.
Condition:
During our testing of payroll, we noted the Center requested reimbursement for two individuals in
excess of amounts approved in the budget justification and in excess of the annual limit of $203,700
established by HRSA for the year ended September 30, 2022.
Cause:
The Center did not have a formal process in place to ensure that amounts requested for
reimbursement complied with the annual salary limitations required by HRSA. Effect or Potential Effect:
Costs charged to federal awards did not conform to the allowability of cost provisions in 2 CFR Part
200, Subpart E, or the award agreement.
Questioned Costs:
$30,259
Context:
We selected 40 payroll items submitted for reimbursement during the year ended September 30,
2022. Two of 40 items selected were in excess of the annual salary limitations.
Repeat Finding:
No
Recommendation:
We recommend that all payroll reimbursement requests be reviewed prior to submission to ensure
that all amounts requested are below amounts approved per the grant agreement, and below annual
limitations as set by HRSA
View of Responsible Officials:
See accompanying Corrective Action Plan.
FINDING 2022-005 – Reporting
SIGNIFICANT DEFICIENCY, NONCOMPLIANCE
Identification of the Federal Program:
U.S. Department of Health and Human Services
93.224/93.527 Health Center Program Cluster
Criteria:
In accordance with 2 CFR Part 200.303(a), the auditee must establish and maintain internal control
over the federal award that provides reasonable assurance that the auditee is managing the federal
award in compliance with federal statutes, regulations, and terms and conditions of the federal award.
Section 200.512 of the Uniform Guidance states that the audit, the data collection form, and the
reporting package must be submitted within 30 calendar days after the auditee receives the auditors’
report, or nine months after the end of the audit period (whichever is earlier).
Condition:
The Center did not complete its audit report prior to the required deadline.
Cause:
Due to a delay in the compiling of records related to the audit, the Center was not in compliance with
the reporting requirements.
Effect or Potential Effect:
The Center was not in compliance with the annual reporting of its data collection form.
Questioned Costs:
None
Repeat Finding:
No
Recommendation:
We recommend that the Center complete its audits and submit the required reports by the deadline.
View of Responsible Officials:
See accompanying Corrective Action Plan.