Audit 38529

Finding 2022-001 - Cash Management (Internal Control over Compliance/Compliance) ALN No.: 93.829 - Section 223 Demonstration Programs to Improve Community Mental Health Services Award Year: January 1, 2022 - December 31, 2022 Federal Agency: United States Department of Health and Human Services Pass Through Entity: Not applicable Criteria: Management is responsible for controls and compliance over cash management. Condition/Context: For 1 out of 40 selections, an invoice was claimed for reimbursement prior to being paid by South Shore in the amount of $420. The sampling method was nonstatistical sampling. Cause: There was not proper review and oversight over the individual preparing the monthly claims for reimbursement. Effect: South Shore has not complied with the specific requirements for cash management as described in the Uniform Guidance. Costs may have been claimed for reimbursement prior to being eligible. Questioned Costs: None. Recommendation: South Shore should develop an internal control process for proper preparation and review of the monthly claims for reimbursement. Views of Responsible Officials: Management agrees with the recommendation and plans to put in place an appropriate internal control process.

Finding 2022-002 - Activities Allowed or Unallowed & Allowable Costs/Cost Principles (Internal Control over Compliance/Compliance) ALN No.: 93.829 - Section 223 Demonstration Programs to Improve Community Mental Health Services Award Year: January 1, 2022 ? December 31, 2022 Federal Agency: United States Department of Health and Human Services Pass Through Entity: Not applicable Criteria: 2 CFR Part 200.303(a) of the Uniform Guidance requires all non-Federal entities to establish and maintain effective internal control over the Federal awards that provides reasonable assurance that the non-Federal entity is managing the Federal awards in compliance with Federal statutes, regulations, and the terms and conditions of the Federal awards. In addition, 2 CFR section 200.405 requires federal awards be expended only for allowable activities. Condition/Context: South Shore made a clerical error in calculating allocated payroll amount claimed for 1 selection tested out of 40 selections leading to an error of $118. The sampling method was nonstatistical sampling. Cause: There was not proper review and oversight over the individual preparing the monthly claims for reimbursement. Effect: South Shore has not complied with the specific requirements for activities allowed or unallowed and allowable costs/cost principles as described in the Uniform Guidance. Unallowable costs were charged to the federal program. Questioned Costs: None. Recommendation: South Shore should develop an internal control process for proper preparation and review of the monthly claims for reimbursement. Views of Responsible Officials: Management agrees with the recommendation and plans to put in place an appropriate internal control process.

Finding 2022-003 - Procurement (Compliance) ALN No.: 93.829 - Section 223 Demonstration Programs to Improve Community Mental Health Services Award Year: January 1, 2022 ? December 31, 2022 Federal Agency: United States Department of Health and Human Services Pass Through Entity: Not applicable Criteria: Under 2 CFR Part 200.318(a) of the Uniform Guidance the non-Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards for the acquisition of property or services required under a Federal award or subaward. The non-Federal entity's documented procurement procedures must conform to the procurement standards identified in 2 CFR Part 200.317 through 200.327. Condition/Context: South Shore does not have documented procurement procedures in accordance with Uniform guidance standards. Cause: South Shore did not adequately document in form of a written procurement policy, however they were aware of and were following the federal procurement standards under the Uniform Guidance. Effect: South Shore has not complied with the specific requirements for procurement as described in the Uniform Guidance. South Shore is following applicable standards but did not have a formally documented policy. Questioned Costs: None. Recommendation: South Shore should develop a documented procurement policy in accordance with the Uniform Guidance. Views of Responsible Officials: Management agrees with the recommendation and plans to develop a formal procurement policy.

Finding 2022-001 - Cash Management (Internal Control over Compliance/Compliance) ALN No.: 93.829 - Section 223 Demonstration Programs to Improve Community Mental Health Services Award Year: January 1, 2022 - December 31, 2022 Federal Agency: United States Department of Health and Human Services Pass Through Entity: Not applicable Criteria: Management is responsible for controls and compliance over cash management. Condition/Context: For 1 out of 40 selections, an invoice was claimed for reimbursement prior to being paid by South Shore in the amount of $420. The sampling method was nonstatistical sampling. Cause: There was not proper review and oversight over the individual preparing the monthly claims for reimbursement. Effect: South Shore has not complied with the specific requirements for cash management as described in the Uniform Guidance. Costs may have been claimed for reimbursement prior to being eligible. Questioned Costs: None. Recommendation: South Shore should develop an internal control process for proper preparation and review of the monthly claims for reimbursement. Views of Responsible Officials: Management agrees with the recommendation and plans to put in place an appropriate internal control process.

Finding 2022-002 - Activities Allowed or Unallowed & Allowable Costs/Cost Principles (Internal Control over Compliance/Compliance) ALN No.: 93.829 - Section 223 Demonstration Programs to Improve Community Mental Health Services Award Year: January 1, 2022 ? December 31, 2022 Federal Agency: United States Department of Health and Human Services Pass Through Entity: Not applicable Criteria: 2 CFR Part 200.303(a) of the Uniform Guidance requires all non-Federal entities to establish and maintain effective internal control over the Federal awards that provides reasonable assurance that the non-Federal entity is managing the Federal awards in compliance with Federal statutes, regulations, and the terms and conditions of the Federal awards. In addition, 2 CFR section 200.405 requires federal awards be expended only for allowable activities. Condition/Context: South Shore made a clerical error in calculating allocated payroll amount claimed for 1 selection tested out of 40 selections leading to an error of $118. The sampling method was nonstatistical sampling. Cause: There was not proper review and oversight over the individual preparing the monthly claims for reimbursement. Effect: South Shore has not complied with the specific requirements for activities allowed or unallowed and allowable costs/cost principles as described in the Uniform Guidance. Unallowable costs were charged to the federal program. Questioned Costs: None. Recommendation: South Shore should develop an internal control process for proper preparation and review of the monthly claims for reimbursement. Views of Responsible Officials: Management agrees with the recommendation and plans to put in place an appropriate internal control process.

Finding 2022-003 - Procurement (Compliance) ALN No.: 93.829 - Section 223 Demonstration Programs to Improve Community Mental Health Services Award Year: January 1, 2022 ? December 31, 2022 Federal Agency: United States Department of Health and Human Services Pass Through Entity: Not applicable Criteria: Under 2 CFR Part 200.318(a) of the Uniform Guidance the non-Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards for the acquisition of property or services required under a Federal award or subaward. The non-Federal entity's documented procurement procedures must conform to the procurement standards identified in 2 CFR Part 200.317 through 200.327. Condition/Context: South Shore does not have documented procurement procedures in accordance with Uniform guidance standards. Cause: South Shore did not adequately document in form of a written procurement policy, however they were aware of and were following the federal procurement standards under the Uniform Guidance. Effect: South Shore has not complied with the specific requirements for procurement as described in the Uniform Guidance. South Shore is following applicable standards but did not have a formally documented policy. Questioned Costs: None. Recommendation: South Shore should develop a documented procurement policy in accordance with the Uniform Guidance. Views of Responsible Officials: Management agrees with the recommendation and plans to develop a formal procurement policy.