Finding 2024-003 U.S. Department of Housing and Urban Development (HUD) Assistance Listing Number 14.218 – CDBG - Entitlement Grants Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Payroll) Repeat Finding: No Criteria: In accordance with 2 CFR §200.303, The non-federal entity must: (a) Establish and maintain effective internal controls 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 In accordance with 2 CFR 200.430: (i) Standards for Documentation of Personnel Expenses (1) 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; (iv) Encompass both federally assisted and all other activities compensated by the non-federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-federal entity’s written policy; (v) Comply with the established accounting policies and practices of the non-federal entity; and (vi) Support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one federal award; a federal award and non-federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. Condition and Context: For the 3 out of 3 employees selected for testing, the timesheet does not support the allocation of work performed to be funded by the federal program. Cause: Timesheets do not report hours by program, so payroll expenses are not allocated to the federal programs based off actual time spent on the grant program. Effect or Potential Effect: Failure to allocate employee pay in accordance with federal requirements could result in a loss of funding. Unallowed costs could be charged to the grant. Questioned Costs: Unknown. Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report
Finding 2024-008 U.S. Department of Health and Human Services Assistance Listing Number 93.224, 93.527 – Health Center Program Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Payroll) Repeat Finding: No Criteria: In accordance with 2 CFR §200.303, The non-federal entity must: (a) 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 In accordance with 2 CFR 200.430: (i) Standards for Documentation of Personnel Expenses (1) 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; (iv) Encompass both federally assisted and all other activities compensated by the non-federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-federal entity’s written policy; (v) Comply with the established accounting policies and practices of the non-federal entity; and (vi) Support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. Condition and Context: For the 4 out of 4 employees selected for testing, the timesheet does not support the allocation of work performed to be funded by the federal program. Cause: Timesheets does not report hours by program, so payroll expenses are not allocated to the federal programs based off actual time spent on the grant program. Effect or Potential Effect: Failure to allocate employee pay in accordance with federal requirements could result in a loss of funding. Unallowed costs could be charged to the grant. Section III - Federal Award Findings and Questioned Costs (continued) Finding 2024-008 (continued) Questioned Costs: Unknown. Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding 2024-009 U.S. Department of Health and Human Services Assistance Listing Number 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Cash Management Repeat Finding: No Criteria: In accordance with 2 CFR 200.302: Financial management, each recipient must expend and account for the federal award in accordance with state laws and procedures for expending and accounting for the recipient’s own funds. In addition, the state’s and the other non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; and the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the federal statutes, regulations, and the terms and conditions of the federal award. Condition and Context: For 1 out of 3 selections, we were unable to agree the drawdown amount to the general ledger to ensure funds were expended prior to requesting reimbursement. Additionally, for 1 out of 3 selections, there was a misapplied payment and incorrect drawdown was requested. Cause: Controls surrounding the cash drawdown process are not operating effectively. Expenditures are not reviewed prior to submission of request. Management could not reconcile information presented in the expenditure report to the underlying records. Effect or Potential Effect: Expenditures reported to the federal government could be inaccurate. Questioned Costs: Unknown. Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed and approved before requests have been submitted. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding 2024-010 U.S. Department of Health and Human Services Assistance Listing Number 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Repeat Finding: Yes, 2023-005 Criteria: According to 42 USC 254b(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g), and 42 CFR sections 56.303(e), (f), and (g)), health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition and Context: The City did not provide the support showing compliance for 25 out of 25 patients selected. Cause: There is no management oversight in this area. Also, employees have not been properly trained and are not consistently utilizing the Allscripts software that maintains patient data. Effect or Potential Effect: The City is not compliant with federal regulations which could result in the federal government imposing additional requirements or withholding, disallowing or suspending grant funds. Questioned Costs: Unknown. Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding 2024-004 U.S. Department of Health and Human Services Assistance Listing Number 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Cash Management Repeat Finding: No Criteria: In accordance with 2 CFR 200.302: Financial management. (a) Each recipient must expend and account for the federal award in accordance with state laws and procedures for expending and accounting for the recipient’s own funds. In addition, the state’s and the other non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; and the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the federal statutes, regulations, and the terms and conditions of the federal award. Condition and Context: For 1 out of 1 selection, we were unable to agree the drawdown amount to the general ledger to ensure funds were being expended prior to requesting reimbursement. Cause: Controls surrounding the cash drawdown process are not operating effectively. Management could not reconcile information presented in the expenditure report to the underlying records. Effect or Potential Effect: Expenditures are not reviewed prior to submission of request. Expenditures reported to the federal government could be inaccurate. Questioned Costs: $37,527.16. Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed and approved before requests have been submitted. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding 2024-005 U.S. Department of Health and Human Services Assistance Listing Number 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Reporting – Financial Report Repeat Finding: Yes, 2023-010 Criteria: Quarterly SF-425 Federal Financial Reports must be submitted to the HHS Payment Management System 30 days after the end of each quarter of the federal fiscal year. Condition and Context: We reviewed the SF-425 submitted for the period of July 1, 2021 through February 29, 2024 and noted the report was originally submitted on June 18, 2024. Quarterly reports as required were not submitted. Cause: Proper monitoring of grant report submissions was not performed. Effect or Potential Effect: Failure to comply with reporting requirements can result in deferral or restrictions of future funding decisions by the funding agency. Questioned Costs: None. Recommendation: Program management and the Finance Department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding 2024-006 U.S. Department of Health and Human Services Assistance Listing Number 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Repeat Finding: No Criteria: Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282), as amended by Section 6202 of Pub. L. No. 110-252, hereafter referred as the “Transparency Act” that are codified in 2 CFR Part 170, recipients (i.e., direct recipients) of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Condition and Context: The City is a direct recipient of Community Programs to Improve Minority Health Grant Program funds from the Department of Health and Human Services and provided first-tier subawards greater than $30,000. The City did not provide support showing submission of their FFATA reporting. Cause: Management does not have procedures in place to ensure subrecipients meeting the reporting requirement are entered into the FSRS portal. Effect or Potential Effect: The City did not report its first-tier subawards in accordance with the Transparency Act requirements. Transactions Tested Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements None None N/A N/A N/A Dollar Amount of Tested Transactions Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements $761,358 $761,358 N/A N/A N/A Questioned Costs: None. Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding 2024-007 U.S. Department of Health and Human Services Assistance Listing Number 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes, 2023-007, 2023-008, 2023-009 Criteria: A pass-through entity (PTE) must clearly identify to the subrecipient the award as a subaward at the time of subaward (or subsequent subaward modification) by providing the information described in 2 CFR section 200.331(a)(1); all requirements imposed by the PTE on the subrecipient so that the federal award is used in accordance with federal statutes, regulations, and the terms and conditions of the award (2 CFR section 200.331(a)(2)); and any additional requirements that the PTE imposes on the subrecipient in order for the PTE to meet its own responsibility for the federal award (e.g., financial, performance, and special reports) (2 CFR section 200.331(a)(3)). A PTE must also evaluate each subrecipient’s risk of noncompliance for purposes of determining the appropriate subrecipient monitoring related to the subaward (2 CFR section 200.332(b)),and monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals (2 CFR sections 200.332(d) through (f)). Condition and Context: For 1 out of 1 selection, the City was not able to provide support showing evidence of the risk assessment performed prior to granting funds to the subrecipient and of the monitoring of the subrecipient during the year. Additionally, various information related to the funding source and the grant were missing on the memorandum of understanding (assistance listing number, federal department grantor, single audit requirements, etc.) Cause: The program has had significant employee turnover and there was a lack of documentation of these policies and procedures. Program management does not have knowledge of the process used to select subrecipients. Monitoring procedures performed were not documented and reports submitted by the subrecipients were not reviewed. Effect or Potential Effect: Failure to explicitly state federally-imposed requirements and regulations may result in noncompliance by the subrecipient. Selecting subrecipients without a formal evaluation process and performing minimal monitoring procedures increases the risk of noncompliance for the City and could lead to a loss of funding if the subrecipients are deemed noncompliant. Questioned Costs: Unknown. Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Uniform Guidance, as noted in Section 200.331(a). Additionally, program management should develop standardized procedures for selecting and granting subawards. These procedures should be formalized and maintained for future reference. Brief minutes of progress meetings should be taken to show that monitoring is taking place. All reporting by the subrecipient should be reviewed by management of the program. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.