Finding 2023-006: Cash Management – Significant Deficiency Information on the federal program: Federal program is Crime Victim Assistance from the U.S. Department of Justice passed through the Criminal Justice Information Authority. Criteria: Under 2 CFR 200.305, non-federal entities must minimize the time between drawing federal funds and disbursing those funds for grant-related expenditures. For cost-reimbursement grants, entities should only request reimbursement for costs that have already been incurred. Condition: The Organization drew down federal funds before incurring the related expenditures. Draw request amounts were based on estimated costs instead of actual, supported expenditures. Management indicated this occurred due to an oversight that resulted in estimated draw requests being submitted. Cause: The Organization did not have adequate procedures in place to ensure draw requests were based solely on actual expenditures incurred under the grant. Effect: Drawing funds prior to incurring allowable costs is noncompliant with federal cash management requirements and may result in the federal government or the pass-through entity requiring repayment of improperly drawn funds. Additionally, early draws increase the risk that federal funds may be used for non-allowable or unsupported purposes. Questioned Costs: None. Context: During our testing of drawdown activity, we identified instances in which the Organization submitted draw requests based on estimated expenditures rather than actual incurred costs. The sampled drawdown was requested before the underlying expenditures occurred, indicating that the Organization’s draw procedures allowed submissions that were not tied to actual costs at the time of the request. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend that management implement procedures to ensure that all draw requests are based strictly on incurred, supported expenditures. Draw requests should reflect the actual expenditures for the reporting period, and an individual should be assigned responsibility for monitoring the timing and accuracy of draw submissions. Views of responsible officials and planned corrective actions: Subsequent to this grant commencing, the Organization hired a new grant and partnership specialist. This specialist reviews all draws to ensure that the draw is for reimbursement for actual expenditure and not estimated expenditure. Reports and draws are also reviewed by the vice president of finance.
Finding 2023-007: Document Retention – Material Weakness Information on the federal program: Federal program is Crime Victim Assistance from the U.S. Department of Justice passed through the Criminal Justice Information Authority. Criteria: Under 2 CFR 200.334, non-federal entities must retain financial and programmatic records, supporting documentation, statistical records, and all other records pertinent to a federal award for the required retention period. Records must be maintained in a manner that allows them to be readily accessible for audit and monitoring purposes. Effective internal controls include maintaining complete, organized, and retrievable documentation to support financial reporting and compliance. Condition: The Organization does not have an effective document retention process or internal controls to ensure that key financial records are consistently preserved, organized, and readily retrievable. Supporting documentation such as invoices, contracts, reconciliations, journal entry support, and grant documentation was frequently incomplete, missing, or delayed in being provided. These gaps resulted in incomplete audit trails and limited management’s ability to demonstrate the completeness, accuracy, and validity of financial information. Cause: The Organization has not designed, implemented, or maintained adequate document retention procedures, nor assigned responsibility to ensure consistent storage, organization, and retrieval of supporting financial documentation. Effect: Without complete and accessible supporting documentation, the Organization cannot substantiate recorded amounts, validate the occurrence or completeness of transactions, or demonstrate the functioning of key internal controls. This increases the risk that material misstatements in the financial statements or noncompliance with federal requirements may not be prevented or detected in a timely manner. Questioned Costs: $29,414 Context: During the audit, we requested various supporting documents needed to verify financial transactions, account balances, and management representations for the period under audit. In multiple instances, the Organization was unable to locate or provide the requested documentation in a timely manner. These difficulties occurred across several financial areas, including invoices, reconciliations, journal entry support, grant-related documentation, and valuation records, indicating that document retention challenges were pervasive rather than isolated to one type of record. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend that management implement a comprehensive document retention and recordkeeping policy that establishes standardized retention requirements for all key financial documentation, including invoices, contracts, reconciliations, journal entries, and grant support. Management should develop procedures for centralized and secure storage, either physical or electronic, to ensure records are properly preserved and readily accessible. Additionally, periodic monitoring should be performed to confirm compliance with retention procedures, and staff should receive training to reinforce expectations regarding documentation maintenance and timely retrieval. Views of responsible officials and planned corrective actions: Subsequent to this grant commencing, the Organization hired a new grant and partnership specialist. This specialist attaches all relevant support for expenditure to the internal monthly grant reporting and ensures that all expenditures are fully supported by appropriate detail. This detail is on a shared drive with finance and is reviewed by the vice president of finance.
Finding 2023-008: Procurement – Significant Deficiency Information on the federal program: Federal program is Crime Victim Assistance from the U.S. Department of Justice passed through the Criminal Justice Information Authority. Criteria: Non-federal entities other than states must follow the procurement standards set out in 2 CFR sections 200.318 through 200.327. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statues and the procurement requirements identified in 2 CFR Part 200. Condition: The Organization does not maintain a formal procurement policy and procedures that meets the requirements of the Uniform Guidance, including procedures addressing allowable costs exceeding the small purchase threshold. The lack of such a formal policy increases the risk that purchases are made that do not comply with Uniform Guidance. Cause: The Organization has not implemented a formal procurement policy and procedures that meets the requirements for the Uniform Guidance. Effect: The lack of such a formal policy increases the risk that purchases are made that do not comply with Uniform Guidance requirements. Questioned Costs: None. Context: As part of our testing over procurement standards under the Uniform Guidance, we requested documentation supporting the Organization’s procurement policies and procedures, including thresholds, required competition, documentation requirements, and approval processes. The Organization was unable to provide a formalized or adopted procurement policy. Additionally, procurement documentation reviewed during the audit indicated that purchases were made without evidence of compliance with federal procurement standards, confirming that the deficiency was systemic and not limited to a single transaction or department. Identification as a Repeat Finding: 2022-008 Recommendation: We recommend that management implement a formal procurement policy and procedures that meets the requirements of the Uniform Guidance. Views of responsible officials and planned corrective actions: While Saint Anthony Hospital has a procurement policy in place, we need to order computers within a certain time frame in order to secure funds from the grant and utilize our main supplier. The procurement policy as well as all policies are reviewed every three years to comply with Joint Commission Standards. Saint Anthony will review its existing procurement policy to ensure that all elements required by the Uniform Guidance are incorporated. The review was completed on March 28, 2025.