Audit 359497

FY End
2023-06-30
Total Expended
$1.03M
Findings
12
Programs
3
Organization: Substance Abuse Services, Inc. (PA)
Year: 2023 Accepted: 2025-06-23

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
565799 2023-001 Significant Deficiency - P
565800 2023-001 Significant Deficiency - P
565801 2023-001 Significant Deficiency - P
565802 2023-002 Significant Deficiency Yes AB
565803 2023-002 Significant Deficiency Yes AB
565804 2023-002 Significant Deficiency Yes AB
1142241 2023-001 Significant Deficiency - P
1142242 2023-001 Significant Deficiency - P
1142243 2023-001 Significant Deficiency - P
1142244 2023-002 Significant Deficiency Yes AB
1142245 2023-002 Significant Deficiency Yes AB
1142246 2023-002 Significant Deficiency Yes AB

Programs

Contacts

Name Title Type
D28NK3UH5KW7 Denise Holden Auditee
7172150798 Michael Mark Auditor
No contacts on file

Notes to SEFA

Title: NOTE 1 BASIS OF PRESENTATION Accounting Policies: NOTE 2 SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Substance Abuse Services, Inc. did not elect to use the 10% de minimis indirect cost rate. Calculation of 40% Rule: Total federal expenditures per schedule $ 1,033,183 Major Program: Grant Program Title Federal ALN # Total Expended Opioid STR Grant 93.788 $ 504,340 Total (48.81% of total federal expenditures) $ 1,033,183 De Minimis Rate Used: N Rate Explanation: Substance Abuse Services, Inc. did not elect to use the 10% de minimis indirect cost rate. The accompanying schedule of expenditures of federal awards (the Schedule) includes the federal grant activity of Substance Abuse Services, Inc. under programs of the federal government for the year ended June 30, 2023. The information in this Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. Because the Schedule presents only a selected portion of the operations of Substance Abuse Services, Inc., it is not intended to and does not present the financial position or changes in net assets of Substance Abuse Services, Inc.
Title: NOTE 2 SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Accounting Policies: NOTE 2 SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Substance Abuse Services, Inc. did not elect to use the 10% de minimis indirect cost rate. Calculation of 40% Rule: Total federal expenditures per schedule $ 1,033,183 Major Program: Grant Program Title Federal ALN # Total Expended Opioid STR Grant 93.788 $ 504,340 Total (48.81% of total federal expenditures) $ 1,033,183 De Minimis Rate Used: N Rate Explanation: Substance Abuse Services, Inc. did not elect to use the 10% de minimis indirect cost rate. Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Substance Abuse Services, Inc. did not elect to use the 10% de minimis indirect cost rate. Calculation of 40% Rule: Total federal expenditures per schedule $ 1,033,183 Major Program: Grant Program Title Federal ALN # Total Expended Opioid STR Grant 93.788 $ 504,340 Total (48.81% of total federal expenditures) $ 1,033,183

Finding Details

Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.303(a) states, “The non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” A good internal control structure consists of proper segregation of duties where no one person is involved in all aspects of a given transaction. This includes proper segregation of the following functions: authorization of transactions, custody of assets, and recordkeeping. Condition During the course of the audit, we noted improper segregation of duties over cash disbursements and payroll: Cash Disbursements: During the year ended June 30, 2023, the bookkeeper had access to a signature stamp along with full access to the general ledger. During our audit, we noted that there is inconsistently documented approval of nonpayroll expenses. Payroll: During our audit, we noted that there is no documented review and approval of the biweekly payrolls or timesheets. Cause The Organization has made a reasonable effort to design proper controls, but has faced challenges in implementing them effectively, due to growth across multiple locations and frequent turnover. Effect Without proper segregation of duties or proper approval processes over cash disbursements, funds could be misappropriated without detection by management or the Board. A lack of proper segregation over payroll controls such as review and approval of biweekly payrolls and timesheets could result in ghost employees on the Organization’s payroll or overpayment of hours and rates. Questioned Costs None Perspective Information During the audit we gained an understanding of the Organization’s internal controls through inquiry and observation, and by examining one item from each of the three cycles: cash receipts, cash disbursements, and payroll. We also tested a sample of forty (40) non-payroll cash disbursements and identified four (4) with no authorization. The Organization does contract with an outside accounting firm who reviews all transactions and performs reconciliations of the accounting records. Identification as a repeat finding There was no similar finding in the prior year. Recommendation We recommend that the Organization implement policies and procedures, including reviews and reconciliations where necessary, which ensure that no one individual is involved in all aspects of the cash disbursements and payroll processes. The Organization should review these processes and segregate duties as much as considered practical. We recommend that all non-payroll expenses be approved before disbursement and that all time sheets and biweekly payrolls be reviewed and approved by the appropriate supervisor/management. We recommend that control of the signature stamp be moved to a different member of the Carlisle office who does not have edit access to the accounting software, and that it continues to only be used at the approval of the Board Chair. View of Responsible Official Currently, based on the capacity of the Organization’s staffing pool, the most efficient and effective means of review and reconciliation of cash disbursements and payroll is the Organization’s Board Chair and CEO reviewing the cash disbursements and payroll every two weeks, prior to payments being made. The Organization’s bookkeeper forwards the Board Chair and CEO a listing of cash disbursements and payroll due with the suggested payments. The Board Chair and CEO each will ask questions and formally “approve” or “disapprove” each transaction, prior to any payments. Once reviewed, the CEO will contact the bookkeeper with the amounts to pay. Also, the Organization’s outsourced accountant will review and approve each monthly bank reconciliation and bank statement for all Organization accounts, as well as the monthly credit card statements. The outsourced accountant does not have the ability to access the monthly bank statements and make purchases. Going forward, the Organization’s Director of Communications will retain the Board Chair’s check stamp. The Director of Communication will only be allowed to use the Board Chair’s check stamp once the Board Chair and CEO approved payment.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.303(a) states, “The non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” A good internal control structure consists of proper segregation of duties where no one person is involved in all aspects of a given transaction. This includes proper segregation of the following functions: authorization of transactions, custody of assets, and recordkeeping. Condition During the course of the audit, we noted improper segregation of duties over cash disbursements and payroll: Cash Disbursements: During the year ended June 30, 2023, the bookkeeper had access to a signature stamp along with full access to the general ledger. During our audit, we noted that there is inconsistently documented approval of nonpayroll expenses. Payroll: During our audit, we noted that there is no documented review and approval of the biweekly payrolls or timesheets. Cause The Organization has made a reasonable effort to design proper controls, but has faced challenges in implementing them effectively, due to growth across multiple locations and frequent turnover. Effect Without proper segregation of duties or proper approval processes over cash disbursements, funds could be misappropriated without detection by management or the Board. A lack of proper segregation over payroll controls such as review and approval of biweekly payrolls and timesheets could result in ghost employees on the Organization’s payroll or overpayment of hours and rates. Questioned Costs None Perspective Information During the audit we gained an understanding of the Organization’s internal controls through inquiry and observation, and by examining one item from each of the three cycles: cash receipts, cash disbursements, and payroll. We also tested a sample of forty (40) non-payroll cash disbursements and identified four (4) with no authorization. The Organization does contract with an outside accounting firm who reviews all transactions and performs reconciliations of the accounting records. Identification as a repeat finding There was no similar finding in the prior year. Recommendation We recommend that the Organization implement policies and procedures, including reviews and reconciliations where necessary, which ensure that no one individual is involved in all aspects of the cash disbursements and payroll processes. The Organization should review these processes and segregate duties as much as considered practical. We recommend that all non-payroll expenses be approved before disbursement and that all time sheets and biweekly payrolls be reviewed and approved by the appropriate supervisor/management. We recommend that control of the signature stamp be moved to a different member of the Carlisle office who does not have edit access to the accounting software, and that it continues to only be used at the approval of the Board Chair. View of Responsible Official Currently, based on the capacity of the Organization’s staffing pool, the most efficient and effective means of review and reconciliation of cash disbursements and payroll is the Organization’s Board Chair and CEO reviewing the cash disbursements and payroll every two weeks, prior to payments being made. The Organization’s bookkeeper forwards the Board Chair and CEO a listing of cash disbursements and payroll due with the suggested payments. The Board Chair and CEO each will ask questions and formally “approve” or “disapprove” each transaction, prior to any payments. Once reviewed, the CEO will contact the bookkeeper with the amounts to pay. Also, the Organization’s outsourced accountant will review and approve each monthly bank reconciliation and bank statement for all Organization accounts, as well as the monthly credit card statements. The outsourced accountant does not have the ability to access the monthly bank statements and make purchases. Going forward, the Organization’s Director of Communications will retain the Board Chair’s check stamp. The Director of Communication will only be allowed to use the Board Chair’s check stamp once the Board Chair and CEO approved payment.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.303(a) states, “The non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” A good internal control structure consists of proper segregation of duties where no one person is involved in all aspects of a given transaction. This includes proper segregation of the following functions: authorization of transactions, custody of assets, and recordkeeping. Condition During the course of the audit, we noted improper segregation of duties over cash disbursements and payroll: Cash Disbursements: During the year ended June 30, 2023, the bookkeeper had access to a signature stamp along with full access to the general ledger. During our audit, we noted that there is inconsistently documented approval of nonpayroll expenses. Payroll: During our audit, we noted that there is no documented review and approval of the biweekly payrolls or timesheets. Cause The Organization has made a reasonable effort to design proper controls, but has faced challenges in implementing them effectively, due to growth across multiple locations and frequent turnover. Effect Without proper segregation of duties or proper approval processes over cash disbursements, funds could be misappropriated without detection by management or the Board. A lack of proper segregation over payroll controls such as review and approval of biweekly payrolls and timesheets could result in ghost employees on the Organization’s payroll or overpayment of hours and rates. Questioned Costs None Perspective Information During the audit we gained an understanding of the Organization’s internal controls through inquiry and observation, and by examining one item from each of the three cycles: cash receipts, cash disbursements, and payroll. We also tested a sample of forty (40) non-payroll cash disbursements and identified four (4) with no authorization. The Organization does contract with an outside accounting firm who reviews all transactions and performs reconciliations of the accounting records. Identification as a repeat finding There was no similar finding in the prior year. Recommendation We recommend that the Organization implement policies and procedures, including reviews and reconciliations where necessary, which ensure that no one individual is involved in all aspects of the cash disbursements and payroll processes. The Organization should review these processes and segregate duties as much as considered practical. We recommend that all non-payroll expenses be approved before disbursement and that all time sheets and biweekly payrolls be reviewed and approved by the appropriate supervisor/management. We recommend that control of the signature stamp be moved to a different member of the Carlisle office who does not have edit access to the accounting software, and that it continues to only be used at the approval of the Board Chair. View of Responsible Official Currently, based on the capacity of the Organization’s staffing pool, the most efficient and effective means of review and reconciliation of cash disbursements and payroll is the Organization’s Board Chair and CEO reviewing the cash disbursements and payroll every two weeks, prior to payments being made. The Organization’s bookkeeper forwards the Board Chair and CEO a listing of cash disbursements and payroll due with the suggested payments. The Board Chair and CEO each will ask questions and formally “approve” or “disapprove” each transaction, prior to any payments. Once reviewed, the CEO will contact the bookkeeper with the amounts to pay. Also, the Organization’s outsourced accountant will review and approve each monthly bank reconciliation and bank statement for all Organization accounts, as well as the monthly credit card statements. The outsourced accountant does not have the ability to access the monthly bank statements and make purchases. Going forward, the Organization’s Director of Communications will retain the Board Chair’s check stamp. The Director of Communication will only be allowed to use the Board Chair’s check stamp once the Board Chair and CEO approved payment.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.430(i)(viii) states, “Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that: (A) the system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and (C) the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges made to a Federal award based on budget estimates. All necessary adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated.” Condition During the course of the audit, we noted that employee time charged to multiple programs was based on an estimated percentage of time established at the beginning of the fiscal year. The methodology is allowable when an after-the-fact review of the estimate is completed to ensure the federal award is charged the proper amount. The Organization reviews and adjusts allocations annually but makes changes on a prospective basis. Cause The Organization’s internal controls do not include a process for adjustments to estimated percentages for charging employee time. Effect The potential effects of not reconciling contemporaneous time and effort reporting to allocated payroll expenses could include an over or understatement of salary expenses allocated to the federal grant. Questioned Costs None Perspective Information The finding noted related to four (4) pay periods tested where it was noted that no allocation based on actual time spent on the grants was performed. It was noted that all employees tested were allocated 100% to the grant. Identification as a repeat finding There was a similar finding in the prior year. Recommendation We recommend the Organization develop a process to review the percentages used to charge employee time to the Federal grants during the fiscal year and update accounting records accordingly. View of Responsible Official Currently, the Organization’s CEO and the bookkeeper will review each grant’s funding details prior to the grant’s fiscal year to determine how each employee’s salary percentages should be allocated according to the grant contract. Throughout the fiscal year, the CEO and bookkeeper will meet regularly to review and incorporate any new hires to determine how their salary is expected to be allocated. Additionally, the outsourced accountant will review the allocations periodically throughout the year to ensure that it is being done properly. Over the next year, as considered efficient, the Organization will implement a daily timesheet record, which requires each program service employee to classify their daily time between federal grant programs. At the end of each week, staff members will submit their timesheet to their supervisor. The supervisor will review each week’s daily timesheet to confirm the staff are recognizing their activities properly. At the end of each month, the Organization’s outsourced accountant, will review these timesheets and determine the proper allocation needed to record each employee’s payroll activities in the accounting software by appropriate federal program. This process will allow for the allocation of actuals to each federal program by the end of the month.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.430(i)(viii) states, “Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that: (A) the system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and (C) the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges made to a Federal award based on budget estimates. All necessary adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated.” Condition During the course of the audit, we noted that employee time charged to multiple programs was based on an estimated percentage of time established at the beginning of the fiscal year. The methodology is allowable when an after-the-fact review of the estimate is completed to ensure the federal award is charged the proper amount. The Organization reviews and adjusts allocations annually but makes changes on a prospective basis. Cause The Organization’s internal controls do not include a process for adjustments to estimated percentages for charging employee time. Effect The potential effects of not reconciling contemporaneous time and effort reporting to allocated payroll expenses could include an over or understatement of salary expenses allocated to the federal grant. Questioned Costs None Perspective Information The finding noted related to four (4) pay periods tested where it was noted that no allocation based on actual time spent on the grants was performed. It was noted that all employees tested were allocated 100% to the grant. Identification as a repeat finding There was a similar finding in the prior year. Recommendation We recommend the Organization develop a process to review the percentages used to charge employee time to the Federal grants during the fiscal year and update accounting records accordingly. View of Responsible Official Currently, the Organization’s CEO and the bookkeeper will review each grant’s funding details prior to the grant’s fiscal year to determine how each employee’s salary percentages should be allocated according to the grant contract. Throughout the fiscal year, the CEO and bookkeeper will meet regularly to review and incorporate any new hires to determine how their salary is expected to be allocated. Additionally, the outsourced accountant will review the allocations periodically throughout the year to ensure that it is being done properly. Over the next year, as considered efficient, the Organization will implement a daily timesheet record, which requires each program service employee to classify their daily time between federal grant programs. At the end of each week, staff members will submit their timesheet to their supervisor. The supervisor will review each week’s daily timesheet to confirm the staff are recognizing their activities properly. At the end of each month, the Organization’s outsourced accountant, will review these timesheets and determine the proper allocation needed to record each employee’s payroll activities in the accounting software by appropriate federal program. This process will allow for the allocation of actuals to each federal program by the end of the month.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.430(i)(viii) states, “Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that: (A) the system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and (C) the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges made to a Federal award based on budget estimates. All necessary adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated.” Condition During the course of the audit, we noted that employee time charged to multiple programs was based on an estimated percentage of time established at the beginning of the fiscal year. The methodology is allowable when an after-the-fact review of the estimate is completed to ensure the federal award is charged the proper amount. The Organization reviews and adjusts allocations annually but makes changes on a prospective basis. Cause The Organization’s internal controls do not include a process for adjustments to estimated percentages for charging employee time. Effect The potential effects of not reconciling contemporaneous time and effort reporting to allocated payroll expenses could include an over or understatement of salary expenses allocated to the federal grant. Questioned Costs None Perspective Information The finding noted related to four (4) pay periods tested where it was noted that no allocation based on actual time spent on the grants was performed. It was noted that all employees tested were allocated 100% to the grant. Identification as a repeat finding There was a similar finding in the prior year. Recommendation We recommend the Organization develop a process to review the percentages used to charge employee time to the Federal grants during the fiscal year and update accounting records accordingly. View of Responsible Official Currently, the Organization’s CEO and the bookkeeper will review each grant’s funding details prior to the grant’s fiscal year to determine how each employee’s salary percentages should be allocated according to the grant contract. Throughout the fiscal year, the CEO and bookkeeper will meet regularly to review and incorporate any new hires to determine how their salary is expected to be allocated. Additionally, the outsourced accountant will review the allocations periodically throughout the year to ensure that it is being done properly. Over the next year, as considered efficient, the Organization will implement a daily timesheet record, which requires each program service employee to classify their daily time between federal grant programs. At the end of each week, staff members will submit their timesheet to their supervisor. The supervisor will review each week’s daily timesheet to confirm the staff are recognizing their activities properly. At the end of each month, the Organization’s outsourced accountant, will review these timesheets and determine the proper allocation needed to record each employee’s payroll activities in the accounting software by appropriate federal program. This process will allow for the allocation of actuals to each federal program by the end of the month.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.303(a) states, “The non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” A good internal control structure consists of proper segregation of duties where no one person is involved in all aspects of a given transaction. This includes proper segregation of the following functions: authorization of transactions, custody of assets, and recordkeeping. Condition During the course of the audit, we noted improper segregation of duties over cash disbursements and payroll: Cash Disbursements: During the year ended June 30, 2023, the bookkeeper had access to a signature stamp along with full access to the general ledger. During our audit, we noted that there is inconsistently documented approval of nonpayroll expenses. Payroll: During our audit, we noted that there is no documented review and approval of the biweekly payrolls or timesheets. Cause The Organization has made a reasonable effort to design proper controls, but has faced challenges in implementing them effectively, due to growth across multiple locations and frequent turnover. Effect Without proper segregation of duties or proper approval processes over cash disbursements, funds could be misappropriated without detection by management or the Board. A lack of proper segregation over payroll controls such as review and approval of biweekly payrolls and timesheets could result in ghost employees on the Organization’s payroll or overpayment of hours and rates. Questioned Costs None Perspective Information During the audit we gained an understanding of the Organization’s internal controls through inquiry and observation, and by examining one item from each of the three cycles: cash receipts, cash disbursements, and payroll. We also tested a sample of forty (40) non-payroll cash disbursements and identified four (4) with no authorization. The Organization does contract with an outside accounting firm who reviews all transactions and performs reconciliations of the accounting records. Identification as a repeat finding There was no similar finding in the prior year. Recommendation We recommend that the Organization implement policies and procedures, including reviews and reconciliations where necessary, which ensure that no one individual is involved in all aspects of the cash disbursements and payroll processes. The Organization should review these processes and segregate duties as much as considered practical. We recommend that all non-payroll expenses be approved before disbursement and that all time sheets and biweekly payrolls be reviewed and approved by the appropriate supervisor/management. We recommend that control of the signature stamp be moved to a different member of the Carlisle office who does not have edit access to the accounting software, and that it continues to only be used at the approval of the Board Chair. View of Responsible Official Currently, based on the capacity of the Organization’s staffing pool, the most efficient and effective means of review and reconciliation of cash disbursements and payroll is the Organization’s Board Chair and CEO reviewing the cash disbursements and payroll every two weeks, prior to payments being made. The Organization’s bookkeeper forwards the Board Chair and CEO a listing of cash disbursements and payroll due with the suggested payments. The Board Chair and CEO each will ask questions and formally “approve” or “disapprove” each transaction, prior to any payments. Once reviewed, the CEO will contact the bookkeeper with the amounts to pay. Also, the Organization’s outsourced accountant will review and approve each monthly bank reconciliation and bank statement for all Organization accounts, as well as the monthly credit card statements. The outsourced accountant does not have the ability to access the monthly bank statements and make purchases. Going forward, the Organization’s Director of Communications will retain the Board Chair’s check stamp. The Director of Communication will only be allowed to use the Board Chair’s check stamp once the Board Chair and CEO approved payment.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.303(a) states, “The non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” A good internal control structure consists of proper segregation of duties where no one person is involved in all aspects of a given transaction. This includes proper segregation of the following functions: authorization of transactions, custody of assets, and recordkeeping. Condition During the course of the audit, we noted improper segregation of duties over cash disbursements and payroll: Cash Disbursements: During the year ended June 30, 2023, the bookkeeper had access to a signature stamp along with full access to the general ledger. During our audit, we noted that there is inconsistently documented approval of nonpayroll expenses. Payroll: During our audit, we noted that there is no documented review and approval of the biweekly payrolls or timesheets. Cause The Organization has made a reasonable effort to design proper controls, but has faced challenges in implementing them effectively, due to growth across multiple locations and frequent turnover. Effect Without proper segregation of duties or proper approval processes over cash disbursements, funds could be misappropriated without detection by management or the Board. A lack of proper segregation over payroll controls such as review and approval of biweekly payrolls and timesheets could result in ghost employees on the Organization’s payroll or overpayment of hours and rates. Questioned Costs None Perspective Information During the audit we gained an understanding of the Organization’s internal controls through inquiry and observation, and by examining one item from each of the three cycles: cash receipts, cash disbursements, and payroll. We also tested a sample of forty (40) non-payroll cash disbursements and identified four (4) with no authorization. The Organization does contract with an outside accounting firm who reviews all transactions and performs reconciliations of the accounting records. Identification as a repeat finding There was no similar finding in the prior year. Recommendation We recommend that the Organization implement policies and procedures, including reviews and reconciliations where necessary, which ensure that no one individual is involved in all aspects of the cash disbursements and payroll processes. The Organization should review these processes and segregate duties as much as considered practical. We recommend that all non-payroll expenses be approved before disbursement and that all time sheets and biweekly payrolls be reviewed and approved by the appropriate supervisor/management. We recommend that control of the signature stamp be moved to a different member of the Carlisle office who does not have edit access to the accounting software, and that it continues to only be used at the approval of the Board Chair. View of Responsible Official Currently, based on the capacity of the Organization’s staffing pool, the most efficient and effective means of review and reconciliation of cash disbursements and payroll is the Organization’s Board Chair and CEO reviewing the cash disbursements and payroll every two weeks, prior to payments being made. The Organization’s bookkeeper forwards the Board Chair and CEO a listing of cash disbursements and payroll due with the suggested payments. The Board Chair and CEO each will ask questions and formally “approve” or “disapprove” each transaction, prior to any payments. Once reviewed, the CEO will contact the bookkeeper with the amounts to pay. Also, the Organization’s outsourced accountant will review and approve each monthly bank reconciliation and bank statement for all Organization accounts, as well as the monthly credit card statements. The outsourced accountant does not have the ability to access the monthly bank statements and make purchases. Going forward, the Organization’s Director of Communications will retain the Board Chair’s check stamp. The Director of Communication will only be allowed to use the Board Chair’s check stamp once the Board Chair and CEO approved payment.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.303(a) states, “The non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” A good internal control structure consists of proper segregation of duties where no one person is involved in all aspects of a given transaction. This includes proper segregation of the following functions: authorization of transactions, custody of assets, and recordkeeping. Condition During the course of the audit, we noted improper segregation of duties over cash disbursements and payroll: Cash Disbursements: During the year ended June 30, 2023, the bookkeeper had access to a signature stamp along with full access to the general ledger. During our audit, we noted that there is inconsistently documented approval of nonpayroll expenses. Payroll: During our audit, we noted that there is no documented review and approval of the biweekly payrolls or timesheets. Cause The Organization has made a reasonable effort to design proper controls, but has faced challenges in implementing them effectively, due to growth across multiple locations and frequent turnover. Effect Without proper segregation of duties or proper approval processes over cash disbursements, funds could be misappropriated without detection by management or the Board. A lack of proper segregation over payroll controls such as review and approval of biweekly payrolls and timesheets could result in ghost employees on the Organization’s payroll or overpayment of hours and rates. Questioned Costs None Perspective Information During the audit we gained an understanding of the Organization’s internal controls through inquiry and observation, and by examining one item from each of the three cycles: cash receipts, cash disbursements, and payroll. We also tested a sample of forty (40) non-payroll cash disbursements and identified four (4) with no authorization. The Organization does contract with an outside accounting firm who reviews all transactions and performs reconciliations of the accounting records. Identification as a repeat finding There was no similar finding in the prior year. Recommendation We recommend that the Organization implement policies and procedures, including reviews and reconciliations where necessary, which ensure that no one individual is involved in all aspects of the cash disbursements and payroll processes. The Organization should review these processes and segregate duties as much as considered practical. We recommend that all non-payroll expenses be approved before disbursement and that all time sheets and biweekly payrolls be reviewed and approved by the appropriate supervisor/management. We recommend that control of the signature stamp be moved to a different member of the Carlisle office who does not have edit access to the accounting software, and that it continues to only be used at the approval of the Board Chair. View of Responsible Official Currently, based on the capacity of the Organization’s staffing pool, the most efficient and effective means of review and reconciliation of cash disbursements and payroll is the Organization’s Board Chair and CEO reviewing the cash disbursements and payroll every two weeks, prior to payments being made. The Organization’s bookkeeper forwards the Board Chair and CEO a listing of cash disbursements and payroll due with the suggested payments. The Board Chair and CEO each will ask questions and formally “approve” or “disapprove” each transaction, prior to any payments. Once reviewed, the CEO will contact the bookkeeper with the amounts to pay. Also, the Organization’s outsourced accountant will review and approve each monthly bank reconciliation and bank statement for all Organization accounts, as well as the monthly credit card statements. The outsourced accountant does not have the ability to access the monthly bank statements and make purchases. Going forward, the Organization’s Director of Communications will retain the Board Chair’s check stamp. The Director of Communication will only be allowed to use the Board Chair’s check stamp once the Board Chair and CEO approved payment.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.430(i)(viii) states, “Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that: (A) the system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and (C) the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges made to a Federal award based on budget estimates. All necessary adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated.” Condition During the course of the audit, we noted that employee time charged to multiple programs was based on an estimated percentage of time established at the beginning of the fiscal year. The methodology is allowable when an after-the-fact review of the estimate is completed to ensure the federal award is charged the proper amount. The Organization reviews and adjusts allocations annually but makes changes on a prospective basis. Cause The Organization’s internal controls do not include a process for adjustments to estimated percentages for charging employee time. Effect The potential effects of not reconciling contemporaneous time and effort reporting to allocated payroll expenses could include an over or understatement of salary expenses allocated to the federal grant. Questioned Costs None Perspective Information The finding noted related to four (4) pay periods tested where it was noted that no allocation based on actual time spent on the grants was performed. It was noted that all employees tested were allocated 100% to the grant. Identification as a repeat finding There was a similar finding in the prior year. Recommendation We recommend the Organization develop a process to review the percentages used to charge employee time to the Federal grants during the fiscal year and update accounting records accordingly. View of Responsible Official Currently, the Organization’s CEO and the bookkeeper will review each grant’s funding details prior to the grant’s fiscal year to determine how each employee’s salary percentages should be allocated according to the grant contract. Throughout the fiscal year, the CEO and bookkeeper will meet regularly to review and incorporate any new hires to determine how their salary is expected to be allocated. Additionally, the outsourced accountant will review the allocations periodically throughout the year to ensure that it is being done properly. Over the next year, as considered efficient, the Organization will implement a daily timesheet record, which requires each program service employee to classify their daily time between federal grant programs. At the end of each week, staff members will submit their timesheet to their supervisor. The supervisor will review each week’s daily timesheet to confirm the staff are recognizing their activities properly. At the end of each month, the Organization’s outsourced accountant, will review these timesheets and determine the proper allocation needed to record each employee’s payroll activities in the accounting software by appropriate federal program. This process will allow for the allocation of actuals to each federal program by the end of the month.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.430(i)(viii) states, “Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that: (A) the system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and (C) the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges made to a Federal award based on budget estimates. All necessary adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated.” Condition During the course of the audit, we noted that employee time charged to multiple programs was based on an estimated percentage of time established at the beginning of the fiscal year. The methodology is allowable when an after-the-fact review of the estimate is completed to ensure the federal award is charged the proper amount. The Organization reviews and adjusts allocations annually but makes changes on a prospective basis. Cause The Organization’s internal controls do not include a process for adjustments to estimated percentages for charging employee time. Effect The potential effects of not reconciling contemporaneous time and effort reporting to allocated payroll expenses could include an over or understatement of salary expenses allocated to the federal grant. Questioned Costs None Perspective Information The finding noted related to four (4) pay periods tested where it was noted that no allocation based on actual time spent on the grants was performed. It was noted that all employees tested were allocated 100% to the grant. Identification as a repeat finding There was a similar finding in the prior year. Recommendation We recommend the Organization develop a process to review the percentages used to charge employee time to the Federal grants during the fiscal year and update accounting records accordingly. View of Responsible Official Currently, the Organization’s CEO and the bookkeeper will review each grant’s funding details prior to the grant’s fiscal year to determine how each employee’s salary percentages should be allocated according to the grant contract. Throughout the fiscal year, the CEO and bookkeeper will meet regularly to review and incorporate any new hires to determine how their salary is expected to be allocated. Additionally, the outsourced accountant will review the allocations periodically throughout the year to ensure that it is being done properly. Over the next year, as considered efficient, the Organization will implement a daily timesheet record, which requires each program service employee to classify their daily time between federal grant programs. At the end of each week, staff members will submit their timesheet to their supervisor. The supervisor will review each week’s daily timesheet to confirm the staff are recognizing their activities properly. At the end of each month, the Organization’s outsourced accountant, will review these timesheets and determine the proper allocation needed to record each employee’s payroll activities in the accounting software by appropriate federal program. This process will allow for the allocation of actuals to each federal program by the end of the month.
Opioid STR Grant ALN 93.788 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.430(i)(viii) states, “Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that: (A) the system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and (C) the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges made to a Federal award based on budget estimates. All necessary adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated.” Condition During the course of the audit, we noted that employee time charged to multiple programs was based on an estimated percentage of time established at the beginning of the fiscal year. The methodology is allowable when an after-the-fact review of the estimate is completed to ensure the federal award is charged the proper amount. The Organization reviews and adjusts allocations annually but makes changes on a prospective basis. Cause The Organization’s internal controls do not include a process for adjustments to estimated percentages for charging employee time. Effect The potential effects of not reconciling contemporaneous time and effort reporting to allocated payroll expenses could include an over or understatement of salary expenses allocated to the federal grant. Questioned Costs None Perspective Information The finding noted related to four (4) pay periods tested where it was noted that no allocation based on actual time spent on the grants was performed. It was noted that all employees tested were allocated 100% to the grant. Identification as a repeat finding There was a similar finding in the prior year. Recommendation We recommend the Organization develop a process to review the percentages used to charge employee time to the Federal grants during the fiscal year and update accounting records accordingly. View of Responsible Official Currently, the Organization’s CEO and the bookkeeper will review each grant’s funding details prior to the grant’s fiscal year to determine how each employee’s salary percentages should be allocated according to the grant contract. Throughout the fiscal year, the CEO and bookkeeper will meet regularly to review and incorporate any new hires to determine how their salary is expected to be allocated. Additionally, the outsourced accountant will review the allocations periodically throughout the year to ensure that it is being done properly. Over the next year, as considered efficient, the Organization will implement a daily timesheet record, which requires each program service employee to classify their daily time between federal grant programs. At the end of each week, staff members will submit their timesheet to their supervisor. The supervisor will review each week’s daily timesheet to confirm the staff are recognizing their activities properly. At the end of each month, the Organization’s outsourced accountant, will review these timesheets and determine the proper allocation needed to record each employee’s payroll activities in the accounting software by appropriate federal program. This process will allow for the allocation of actuals to each federal program by the end of the month.