Missing documentation for procurement, suspension and debarment 93.318 Protecting and Improving Health Globally: Building and Strengthening Public Health Impact, Systems, Capacity and Security 93.421 Strengthening Public Health Systems and Services Criteria: Per Uniform Guidance 2 CFR 200.318, any contracts procured with federal funds for over $10,000 should be obtained via a bidding process or documentation is required to show that the contractor is the sole source for the services. In addition, the Organization should keep documentation to show that they have verified that contractors are not suspended or debarred. Condition: Bid or sole source documentation was missing for four out of thirteen items tested (30.8%). We consider this condition to be a significant deficiency for Procurement Suspension & Debarment compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2022 004. Statistical sampling was not used in making sample selections. Questioned costs: None Effect: As a result, the Organization was missing documentation relating to the requirements for procurement, suspension and debarment. Cause: This is due to ineffective controls over the procurement process resulting from staff turnover. Recommendation: Auditors recommend that the Organization maintain all federal award documentation in a location where all authorized personnel have access in order to ensure that it can always be located. We also recommend that management create a process for procurement, including how bids are obtained and maintained for proof of compliance with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with this Single Audit Finding and response is included in the Corrective Action Plan
Late reports, incomplete reports and variances from accounting records 93.011 National Organizations for State and Local Officials 93.318 Protecting and Improving Health Globally: Building and Strengthening Public Health Impact, Systems, Capacity and Security 93.341 Analyses, Research and Studies to Address the Impact of CMS Programs on American Indian/Alaska Native (AI/AN) Beneficiaries and the Health Care System Serving these Beneficiaries 93.421 Strengthening Public Health Systems and Services Criteria: Per Uniform Guidance 2 CFR 200 Subpart D, Performance and Financial Monitoring and Reporting, reports should be submitted within the required timeframe per the grant agreement and should tie out to the financial records. Documentation should also be kept for all financial and programmatic reports submitted for all federal awards. Condition: The Organization did not submit reports timely for five out of ten reports tested (50%). We also noted one report that was incomplete. Additionally, we identified a report in which there was a significant discrepancy between the figures in the accounting records and those presented in the report. We consider this condition to be a material weakness to the Reporting compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2022 005. Statistical sampling was not used in making sample selections. Questioned costs: None Effect: As a result, certain reports were filed late and one was incomplete, which may affect the accuracy of the reports and require additional oversight in the future. Cause: The late reports and variances are due to ineffective controls over reporting resulting from employee turnover, resulting in delays and missing documentation to support the variances. Recommendation: Auditors recommend that grant personnel track all deadlines for submission of reports and that management be aware of these deadlines and track and review all submissions to ensure timely and accurate fillings. If there are delays, the Organization should request and document permission to submit late. The Organization should also maintain all federal award reporting documentation in a location where authorized personnel have access in order to ensure that it can always be located. It is critical to maintain complete and accurate documentation to ensure compliance with Uniform Guidance requirements. Views of Responsible Officials and Planned Corrective Actions: Management agrees with this Single Audit Finding and response is included in the Corrective Action Plan.
Employee not paid approved salary rate and payroll allocation based on incorrect pay rate. Timesheets missing approval. 93.011 National Organizations for State and Local Officials 93.318 Protecting and Improving Health Globally: Building and Strengthening Public Health Impact, Systems, Capacity and Security 93.341 Analyses, Research and Studies to Address the Impact of CMS Programs on American Indian/Alaska Native (AI/AN) Beneficiaries and the Health Care System Serving these Beneficiaries 93.421 Strengthening Public Health Systems and Services Criteria: 2 CFR 200.430 states “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) Be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) Be incorporated into the official records of the non Federal entity; (iii) Reasonably reflect the total activity for which the employee is compensated by the non Federal entity, not exceeding 100% of compensated activities." Condition: During our testing of payroll, we noted twenty one instances of incorrect pay rates, missing timesheet approvals and twenty four payroll allocations based on incorrect pay rates. We consider these to be a significant deficiency in internal control over compliance relating to activities allowed and unallowed and allowable costs/cost principles requirements and is not considered a repeated finding. Statistical sampling was not used in making sample selections. Questioned costs: $4,245 Effect: Employee compensation was not processed using the authorized salary rate, resulting in payroll allocations based on an incorrect pay rate. Additionally, timesheets lacked the required approval signatures. Overall this could result in an employee being incorrectly paid for time worked. Cause: This is due to lack of controls over document retention resulting from employee turnover. Recommendation: Auditors recommend the Organization maintain proper salary rate approval and ensure all pay rates are approved by an appropriate individual and properly paid to employees. We also recommend timesheets should be approved by an appropriate individual and payroll allocations should be based on proper salary rates. Views of Responsible Officials and Planned Corrective Actions: Management agrees with this Single Audit Finding and response is included in the Corrective Action Plan.
Improper monitoring of subrecipients 93.011 National Organizations for State and Local Officials 93.318 Protecting and Improving Health Globally: Building and Strengthening Public Health Impact, Systems, Capacity and Security 93.421 Strengthening Public Health Systems and Services Criteria: 2 CFR 200.232 states “A pass through entity must: (a) Verify that the subrecipient is not excluded or disqualified in accordance with 180.300. Verification methods are provided in 180.300, which include confirming in SAM.gov that a potential subrecipient is not suspended, debarred, or otherwise excluded from receiving Federal funds; (e) Monitor the activities of a subrecipient as necessary to ensure that the subrecipient complied with Federal statutes, regulations, and the terms and conditions of the subaward. The pass through entity is responsible for monitoring the overall performance of a subrecipient to ensure that the goals and objectives of the subaward are achieved. In monitoring a subrecipient, a pass through entity must: (1) Review financial and performance reports. (2) Ensure that the subrecipient takes corrective action on all significant developments that negatively affect the subaward. Significant developments include Single Audit findings related to the subaward, other audit findings, site visits, and written notifications from a subrecipient of adverse conditions which will impact their ability to meet the milestones or the objectives of a subaward. When significant development negatively impact the subaward, a subrecipient must provide the pass through entity with information on their plan for corrective action and any assistance needed to resolve the situation. (3) Issue a management decision for audit findings pertaining only to the Federal ward provided to the subrecipient from the pass through entity as required by 200.521.(4) Resolve audit findings specifically related to the subaward. However, the pass through entity is not responsible for resolving cross cutting audit findings that apply the subaward and other Federal awards or subawards. If a subrecipient has a current Single Audit report and has not been excluded from receiving Federal funding (meaning, has not been debarred or suspended), the pass through entity may rely on the subrecipient’s cognizant agency for audit or oversight agency for audit to perform audit follow up and make management decisions related to cross cutting audit findings in accordance with section 200.513(a)(4)(viii). Such reliance does not eliminate the responsibility of the pass through entity to issue subawards that confirm to agency and award specific requirements, to manage risk through ongoing subaward monitoring, and to monitor the status of the findings that are specifically related to the subaward. (f) Depending up on the pass through entity’s assessment of the risk posed by the subrecipient, the following monitoring tools may be useful for the pass through entity to ensure proper accountability and compliance with program requirements and achievement of performance goals: (1) Providing subrecipients with training and technical assistance on program related matters; (2) Performing site visits to review the subrecipient’s program operations; and (3) Arranging for agreed upon procedures engagements as described in 200.425.” Condition: Auditors noted there was no documentary evidence of the following subrecipient monitoring requirements: obtain budgets for reasonable expenses from subrecipients, SAM.gov suspension and debarment check, site visit documentation, receiving updated audit reports from subrecipients and issuing management decisions over federal award findings for pass through entities. We consider this condition to be a material weakness to the Subrecipient Monitoring compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2022 007. Statistical sampling was not used in making sample selections. Questioned costs: None Effect: As a result, the Organization was missing documentation relating to subrecipient monitoring requirements for the year ended December 31, 2023. Cause: This is due to ineffective controls over subrecipient monitoring resulting in a lack of documentation, miscommunications during employee transitions and the need to train new employees on policies and procedures. Recommendation: Auditors recommend that there are checks at least annually for suspension or debarment and that documentation be maintained for all checks completed. In addition the Organization should follow up and obtain audited financial statements each year from subrecipients and issue management decisions for federal award findings for pass through entities. It is also recommended to improve subrecipient monitoring policies so subrecipient budgets are received as well as site visits conducted of subrecipients. It is critical that subrecipients are properly monitored to ensure that they are complying with Uniform Guidance requirements. Views of Responsible Officials and Planned Corrective Actions: Management agrees with this Single Audit Finding and response is included in the Corrective Action Plan.
Missing Written Cost Allocation Plan and Lack of Documentation Around Allocation Methodology and Lookback on Budget to Actual Analysis 93.011 National Organizations for State and Local Officials 93.318 Protecting and Improving Health Globally: Building and Strengthening Public Health Impact, Systems, Capacity and Security 93.341 Analyses, Research and Studies to Address the Impact of CMS Programs on American Indian/Alaska Native (AI/AN) Beneficiaries and the Health Care System Serving these Beneficiaries 93.421 Strengthening Public Health Systems and Services Criteria: In accordance with the requirements in 2 CFR part 230 establishes cost principles for determining costs of grants, contracts, and other agreements with non profit organizations. The principles are designed to provide that the Federal Government bear its fair share of costs except where restricted or prohibited by law. Administrative expenses are described as: “The expenses under this category are those that have been incurred for the overall general executive, and administration of the organization and other expenses of a general nature that do not relate solely to any major function of the organization." Condition: The Organization does not have a cost allocation plan in place. Due to this, there is a lack of documentation around allocation methodology and lookback on budget to actual analysis. We consider this to be a material weakness in internal controls over compliance with Allowable Costs/Cost Principles and is not considered a repeated finding. Questioned costs: None Effect: As a result, the Organization does not have a written cost allocation plan to follow and administrative costs may not be sufficiently identified. As the Organization has more than one funding source, costs may be inequitably charged to programs. Cause: Although the Organization appears to be allocating costs, they still need to have written cost allocation plan created to make sure the plan is being followed and costs charged appropriately to programs. Recommendation: Auditors recommend the Organization review their system in place for cost allocation and implement a written cost allocation plan to ensure costs are charged appropriately to programs. Views of Responsible Officials and Planned Corrective Actions: Management agrees with this Single Audit Finding and response is included in the Corrective Action Plan.