2024-002. Failure to Maintain Accurate Accounting Records for Federal Awards Criteria: Title 2 U. S. Code of Federal Regulations (CFR) Section 200.303, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires the recipient of federal awards to establish and maintain internal control over federal awards that provide reasonable assurance that the recipient is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal award. One of the objectives of internal control over compliance is to ensure that federal transactions are properly recorded and accounted for in the accounting records in order to permit the preparation of reliable financial statements, including the Schedule of Expenditures of Federal Awards. Condition: Federal grant revenues in the amount of $270,907 were not properly recorded in the accounting records. Cause: Undetermined. Effect: Federal award transactions could be improperly reported in the financial statements and the Schedule of Expenditures of Federal Awards. Recommendation: All future federal grant revenue should be properly recorded in the accounting records.
Finding 2024-001: Rural Rental Housing Loans Assistance Listing Number: 10.415 U.S. Department of Agriculture Compliance Requirement: Eligibility Type of finding: Internal Control Over Compliance (significant deficiency) Criteria: The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards require that the non-Federal entity 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 (2 CFR 200.303(a)). Condition: The Organization did not implement a review or monitoring process to ensure propriety in eligibility determinations and tenant lease agreements for the period June 2024 – December 2024. Specifically, there was no review of eligibility determinations and tenant lease agreements for 8 of 12 tenant files reviewed. Cause: The Administrative Assistants took over completing all tenant eligibility determinations after the previous Executive Director retired in May 2024 resulting in a lack of separate review. Effect: Noncompliance with the Rural Rental Housing Loan requirements may exist and not be detected by the Organization. Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of the Executive Director and Alamosa Administrative Assistant to provide for a review process of tenant eligibility determinations. Grantee’s Response: See corrective action plan.
Finding 2024-001: Rural Rental Housing Loans Assistance Listing Number: 10.415 U.S. Department of Agriculture Compliance Requirement: Eligibility Type of finding: Internal Control Over Compliance (significant deficiency) Criteria: The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards require that the non-Federal entity 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 (2 CFR 200.303(a)). Condition: The Organization did not implement a review or monitoring process to ensure propriety in eligibility determinations and tenant lease agreements for the period June 2024 – December 2024. Specifically, there was no review of eligibility determinations and tenant lease agreements for 8 of 12 tenant files reviewed. Cause: The Administrative Assistants took over completing all tenant eligibility determinations after the previous Executive Director retired in May 2024 resulting in a lack of separate review. Effect: Noncompliance with the Rural Rental Housing Loan requirements may exist and not be detected by the Organization. Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of the Executive Director and Alamosa Administrative Assistant to provide for a review process of tenant eligibility determinations. Grantee’s Response: See corrective action plan.
Finding 2024-001: Rural Rental Housing Loans Assistance Listing Number: 10.415 U.S. Department of Agriculture Compliance Requirement: Eligibility Type of finding: Internal Control Over Compliance (significant deficiency) Criteria: The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards require that the non-Federal entity 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 (2 CFR 200.303(a)). Condition: The Organization did not implement a review or monitoring process to ensure propriety in eligibility determinations and tenant lease agreements for the period June 2024 – December 2024. Specifically, there was no review of eligibility determinations and tenant lease agreements for 8 of 12 tenant files reviewed. Cause: The Administrative Assistants took over completing all tenant eligibility determinations after the previous Executive Director retired in May 2024 resulting in a lack of separate review. Effect: Noncompliance with the Rural Rental Housing Loan requirements may exist and not be detected by the Organization. Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of the Executive Director and Alamosa Administrative Assistant to provide for a review process of tenant eligibility determinations. Grantee’s Response: See corrective action plan.
Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development (Repeat of Finding 2023-002 and 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Criteria: The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards require that the non-Federal entity 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 (2 CFR 200.303(a)). Condition: The Organization has not implemented a review or monitoring process to ensure propriety in eligibility determinations, tenant lease agreements, housing assistance payment requests, and return of funds for vacant units and rent adjustments to contract rent included on the monthly Housing Assistance Payment vouchers. Cause: The compliance responsibilities of the Organization are performed by one person which has made it difficult to establish a proper review process over cash management, eligibility, reporting, and special tests and provisions requirements. Effect: Noncompliance with the Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation requirements may exist and not be detected by the Organization. Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Grantee’s Response: See corrective action plan.
2 CFR §2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR §200.303(a) which states that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).Furthermore, 2 CFR §200.430(i)(1)(i) states "charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The “City of Columbus Fiscal Policies and Procedures for the Administration of HUD Grants Manual” Part II Section C – Standards for Documentation of Personal Services provides the following: All grant funded staff (both city staff and subrecipient staff) will utilize personal activity reports (timesheets). All timesheets will reflect total hours worked, identify the federal grant hours worked, and be signed by either the employee or the supervisor. Furthermore, the City of Columbus Department of Development has established a procedure of timesheet review which requires supervisors review employee timesheets within one week of the pay period end date. This review is evidenced by an electronic signature on the employee-completed timesheet.While the City does have an internal control policy in place in accordance with 2 CFR 430(i)(1)(i), supervisors were not always adhering to the policy which resulted in a deficiency in the application of the control process. During payroll control testing over AL #14.239 Home Investment Partnership Program, it was noted 3 out of the 5 selected worklogs (60%) were not signed by the supervisor within the one-week requirement as required by City policy. Supervisory sign offs occurred between 12 and 32 working days (not including weekends) following the end of the pay period.Failure to follow the established internal control policy and ensuring all time sheets are appropriately approved by a knowledgeable supervisor, within one week of the pay period end date, could result in unallowable costs being allocated to a federal program and could ultimately result in noncompliance and/or a questioned cost. The City should review established policies and procedures with supervisory personnel and evaluate if additional control procedures should be in place to ensure all timesheets are appropriately reviewed timely prior to allocation to a federal program.
2 CFR §2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR §200.303(a) which states that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).Furthermore, 2 CFR §200.430(i)(1)(i) states "charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The “City of Columbus Fiscal Policies and Procedures for the Administration of HUD Grants Manual” Part II Section C – Standards for Documentation of Personal Services provides the following: All grant funded staff (both city staff and subrecipient staff) will utilize personal activity reports (timesheets). All timesheets will reflect total hours worked, identify the federal grant hours worked, and be signed by either the employee or the supervisor. Furthermore, the City of Columbus Department of Development has established a procedure of timesheet review which requires supervisors review employee timesheets within one week of the pay period end date. This review is evidenced by an electronic signature on the employee-completed timesheet.While the City does have an internal control policy in place in accordance with 2 CFR 430(i)(1)(i), supervisors were not always adhering to the policy which resulted in a deficiency in the application of the control process. During payroll control testing over AL #14.239 Home Investment Partnership Program, it was noted 3 out of the 5 selected worklogs (60%) were not signed by the supervisor within the one-week requirement as required by City policy. Supervisory sign offs occurred between 12 and 32 working days (not including weekends) following the end of the pay period.Failure to follow the established internal control policy and ensuring all time sheets are appropriately approved by a knowledgeable supervisor, within one week of the pay period end date, could result in unallowable costs being allocated to a federal program and could ultimately result in noncompliance and/or a questioned cost. The City should review established policies and procedures with supervisory personnel and evaluate if additional control procedures should be in place to ensure all timesheets are appropriately reviewed timely prior to allocation to a federal program.
2 CFR §2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR §200.303(a) which states that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).Furthermore, 2 CFR §200.430(i)(1)(i) states "charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The “City of Columbus Fiscal Policies and Procedures for the Administration of HUD Grants Manual” Part II Section C – Standards for Documentation of Personal Services provides the following: All grant funded staff (both city staff and subrecipient staff) will utilize personal activity reports (timesheets). All timesheets will reflect total hours worked, identify the federal grant hours worked, and be signed by either the employee or the supervisor. Furthermore, the City of Columbus Department of Development has established a procedure of timesheet review which requires supervisors review employee timesheets within one week of the pay period end date. This review is evidenced by an electronic signature on the employee-completed timesheet.While the City does have an internal control policy in place in accordance with 2 CFR 430(i)(1)(i), supervisors were not always adhering to the policy which resulted in a deficiency in the application of the control process. During payroll control testing over AL #14.239 Home Investment Partnership Program, it was noted 3 out of the 5 selected worklogs (60%) were not signed by the supervisor within the one-week requirement as required by City policy. Supervisory sign offs occurred between 12 and 32 working days (not including weekends) following the end of the pay period.Failure to follow the established internal control policy and ensuring all time sheets are appropriately approved by a knowledgeable supervisor, within one week of the pay period end date, could result in unallowable costs being allocated to a federal program and could ultimately result in noncompliance and/or a questioned cost. The City should review established policies and procedures with supervisory personnel and evaluate if additional control procedures should be in place to ensure all timesheets are appropriately reviewed timely prior to allocation to a federal program.
2 CFR §2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR §200.303(a) which states that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).Furthermore, 2 CFR §200.430(i)(1)(i) states "charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The “City of Columbus Fiscal Policies and Procedures for the Administration of HUD Grants Manual” Part II Section C – Standards for Documentation of Personal Services provides the following: All grant funded staff (both city staff and subrecipient staff) will utilize personal activity reports (timesheets). All timesheets will reflect total hours worked, identify the federal grant hours worked, and be signed by either the employee or the supervisor. Furthermore, the City of Columbus Department of Development has established a procedure of timesheet review which requires supervisors review employee timesheets within one week of the pay period end date. This review is evidenced by an electronic signature on the employee-completed timesheet.While the City does have an internal control policy in place in accordance with 2 CFR 430(i)(1)(i), supervisors were not always adhering to the policy which resulted in a deficiency in the application of the control process. During payroll control testing over AL #14.239 Home Investment Partnership Program, it was noted 3 out of the 5 selected worklogs (60%) were not signed by the supervisor within the one-week requirement as required by City policy. Supervisory sign offs occurred between 12 and 32 working days (not including weekends) following the end of the pay period.Failure to follow the established internal control policy and ensuring all time sheets are appropriately approved by a knowledgeable supervisor, within one week of the pay period end date, could result in unallowable costs being allocated to a federal program and could ultimately result in noncompliance and/or a questioned cost. The City should review established policies and procedures with supervisory personnel and evaluate if additional control procedures should be in place to ensure all timesheets are appropriately reviewed timely prior to allocation to a federal program.
2 CFR §2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR §200.303(a) which states that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).Furthermore, 2 CFR §200.430(i)(1)(i) states "charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The “City of Columbus Fiscal Policies and Procedures for the Administration of HUD Grants Manual” Part II Section C – Standards for Documentation of Personal Services provides the following: All grant funded staff (both city staff and subrecipient staff) will utilize personal activity reports (timesheets). All timesheets will reflect total hours worked, identify the federal grant hours worked, and be signed by either the employee or the supervisor. Furthermore, the City of Columbus Department of Development has established a procedure of timesheet review which requires supervisors review employee timesheets within one week of the pay period end date. This review is evidenced by an electronic signature on the employee-completed timesheet.While the City does have an internal control policy in place in accordance with 2 CFR 430(i)(1)(i), supervisors were not always adhering to the policy which resulted in a deficiency in the application of the control process. During payroll control testing over AL #14.239 Home Investment Partnership Program, it was noted 3 out of the 5 selected worklogs (60%) were not signed by the supervisor within the one-week requirement as required by City policy. Supervisory sign offs occurred between 12 and 32 working days (not including weekends) following the end of the pay period.Failure to follow the established internal control policy and ensuring all time sheets are appropriately approved by a knowledgeable supervisor, within one week of the pay period end date, could result in unallowable costs being allocated to a federal program and could ultimately result in noncompliance and/or a questioned cost. The City should review established policies and procedures with supervisory personnel and evaluate if additional control procedures should be in place to ensure all timesheets are appropriately reviewed timely prior to allocation to a federal program.
2 CFR §2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR §200.303(a) which states that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).Furthermore, 2 CFR §200.430(i)(1)(i) states "charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The “City of Columbus Fiscal Policies and Procedures for the Administration of HUD Grants Manual” Part II Section C – Standards for Documentation of Personal Services provides the following: All grant funded staff (both city staff and subrecipient staff) will utilize personal activity reports (timesheets). All timesheets will reflect total hours worked, identify the federal grant hours worked, and be signed by either the employee or the supervisor. Furthermore, the City of Columbus Department of Development has established a procedure of timesheet review which requires supervisors review employee timesheets within one week of the pay period end date. This review is evidenced by an electronic signature on the employee-completed timesheet.While the City does have an internal control policy in place in accordance with 2 CFR 430(i)(1)(i), supervisors were not always adhering to the policy which resulted in a deficiency in the application of the control process. During payroll control testing over AL #14.239 Home Investment Partnership Program, it was noted 3 out of the 5 selected worklogs (60%) were not signed by the supervisor within the one-week requirement as required by City policy. Supervisory sign offs occurred between 12 and 32 working days (not including weekends) following the end of the pay period.Failure to follow the established internal control policy and ensuring all time sheets are appropriately approved by a knowledgeable supervisor, within one week of the pay period end date, could result in unallowable costs being allocated to a federal program and could ultimately result in noncompliance and/or a questioned cost. The City should review established policies and procedures with supervisory personnel and evaluate if additional control procedures should be in place to ensure all timesheets are appropriately reviewed timely prior to allocation to a federal program.
2 CFR §2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR §200.303(a) which states that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).Furthermore, 2 CFR §200.430(i)(1)(i) states "charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The “City of Columbus Fiscal Policies and Procedures for the Administration of HUD Grants Manual” Part II Section C – Standards for Documentation of Personal Services provides the following: All grant funded staff (both city staff and subrecipient staff) will utilize personal activity reports (timesheets). All timesheets will reflect total hours worked, identify the federal grant hours worked, and be signed by either the employee or the supervisor. Furthermore, the City of Columbus Department of Development has established a procedure of timesheet review which requires supervisors review employee timesheets within one week of the pay period end date. This review is evidenced by an electronic signature on the employee-completed timesheet.While the City does have an internal control policy in place in accordance with 2 CFR 430(i)(1)(i), supervisors were not always adhering to the policy which resulted in a deficiency in the application of the control process. During payroll control testing over AL #14.239 Home Investment Partnership Program, it was noted 3 out of the 5 selected worklogs (60%) were not signed by the supervisor within the one-week requirement as required by City policy. Supervisory sign offs occurred between 12 and 32 working days (not including weekends) following the end of the pay period.Failure to follow the established internal control policy and ensuring all time sheets are appropriately approved by a knowledgeable supervisor, within one week of the pay period end date, could result in unallowable costs being allocated to a federal program and could ultimately result in noncompliance and/or a questioned cost. The City should review established policies and procedures with supervisory personnel and evaluate if additional control procedures should be in place to ensure all timesheets are appropriately reviewed timely prior to allocation to a federal program.
2 CFR §2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR §200.303(a) which states that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).Furthermore, 2 CFR §200.430(i)(1)(i) states "charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The “City of Columbus Fiscal Policies and Procedures for the Administration of HUD Grants Manual” Part II Section C – Standards for Documentation of Personal Services provides the following: All grant funded staff (both city staff and subrecipient staff) will utilize personal activity reports (timesheets). All timesheets will reflect total hours worked, identify the federal grant hours worked, and be signed by either the employee or the supervisor. Furthermore, the City of Columbus Department of Development has established a procedure of timesheet review which requires supervisors review employee timesheets within one week of the pay period end date. This review is evidenced by an electronic signature on the employee-completed timesheet.While the City does have an internal control policy in place in accordance with 2 CFR 430(i)(1)(i), supervisors were not always adhering to the policy which resulted in a deficiency in the application of the control process. During payroll control testing over AL #14.239 Home Investment Partnership Program, it was noted 3 out of the 5 selected worklogs (60%) were not signed by the supervisor within the one-week requirement as required by City policy. Supervisory sign offs occurred between 12 and 32 working days (not including weekends) following the end of the pay period.Failure to follow the established internal control policy and ensuring all time sheets are appropriately approved by a knowledgeable supervisor, within one week of the pay period end date, could result in unallowable costs being allocated to a federal program and could ultimately result in noncompliance and/or a questioned cost. The City should review established policies and procedures with supervisory personnel and evaluate if additional control procedures should be in place to ensure all timesheets are appropriately reviewed timely prior to allocation to a federal program.
2 CFR §2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR §200.303(a) which states that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).Furthermore, 2 CFR §200.430(i)(1)(i) states "charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The “City of Columbus Fiscal Policies and Procedures for the Administration of HUD Grants Manual” Part II Section C – Standards for Documentation of Personal Services provides the following: All grant funded staff (both city staff and subrecipient staff) will utilize personal activity reports (timesheets). All timesheets will reflect total hours worked, identify the federal grant hours worked, and be signed by either the employee or the supervisor. Furthermore, the City of Columbus Department of Development has established a procedure of timesheet review which requires supervisors review employee timesheets within one week of the pay period end date. This review is evidenced by an electronic signature on the employee-completed timesheet.While the City does have an internal control policy in place in accordance with 2 CFR 430(i)(1)(i), supervisors were not always adhering to the policy which resulted in a deficiency in the application of the control process. During payroll control testing over AL #14.239 Home Investment Partnership Program, it was noted 3 out of the 5 selected worklogs (60%) were not signed by the supervisor within the one-week requirement as required by City policy. Supervisory sign offs occurred between 12 and 32 working days (not including weekends) following the end of the pay period.Failure to follow the established internal control policy and ensuring all time sheets are appropriately approved by a knowledgeable supervisor, within one week of the pay period end date, could result in unallowable costs being allocated to a federal program and could ultimately result in noncompliance and/or a questioned cost. The City should review established policies and procedures with supervisory personnel and evaluate if additional control procedures should be in place to ensure all timesheets are appropriately reviewed timely prior to allocation to a federal program.
2024-001 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Significant Deficiency in Internal Control Over Compliance – Appropriate Internal Control Structure Related to Compliance Requirements I. Procurement and Suspension and Debarment Criteria: 2 CFR 200.303 includes requirements related to internal controls for federal award programs, including that CICP must, among other things, “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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)”. Condition and Context: We noted CICP did not complete their procurement checklist timely for one specific vendor, in accordance with their written policies. The procurement checklist is CICP’s key control for monitoring procurement and suspension and debarment of vendors. The vendor relationship was an existing relationship, but the vendor had not previously been used for any activities related to federal awards. CICP had other written documentation which provided evidence they followed their procurement process; however, no written documentation was maintained indicating suspension or debarment was reviewed prior to using the vendor for activities related to the federal award. Cause and Effect: Not completing the procurement checklist timely could result in noncompliance related to procurement and suspension and debarment. Recommendation: We recommend the procurement checklist be completed in line with the written policies of CICP. Views of Responsible Officials and Planned Corrective Action: CICP agrees with the recommendation and it was implemented effective 2/14/2025.
Finding 2024-005 – Internal Controls over Federal Awards (Significant Deficiency and Noncompliance)( Repeat finding) Information on the Federal Program: U.S. Department of Justice, Assistance Listing No.16.575 Victims of Crime Act (VOCA) Criteria: 2 CFR 200.303 requires 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 award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition/Context: We selected 50 disbursements for testing. Of those 50, 25 were for payroll and 25 were non-payroll disbursements. Of the 25 non-payroll, 4 lacked documentation of approval for payment.Cause: The Organization did not properly document controls established in its accounting manual to review and approve expenses charged to the grant. Effect: The Organization did not obtain proper approvals according to the policy of established controls. Questioned costs: None Recommendation: We recommend the Organization strengthen its policies and procedures surrounding disbursement and allocation processes to document the review and approval process to meet the control standards. Views of Responsible Officials: Management agrees with this finding. See Management’s View and Corrective Action Plan included at the end of the report.
Finding 2024-001 Reporting Criteria: Pursuant to 2 CFR section 200.303(a), the nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Revolving Loan Fund (RLF) recipients must administer RLFs in accordance with an RLF Plan approved by EDA. Pursuant to 13 CFR 307.14 (a) All RLF Recipients, including those receiving Recapitalization Grants for existing RLFs, must complete and submit an RLF report, using Form ED-209, in a format and at a frequency as required by EDA. Pursuant to 13 CFR 307.14 (b) All RLF Recipients must certify as part of the RLF report to EDA that the RLF is operating in accordance with the applicable RLF Plan and that the information provided is complete and accurate. Condition: There were no adequate internal controls to identify and correct material misstatements in key line items in the Form ED-209, Revolving Loan Fund Financial Report (report) for the Legacy or Cares Revolving Loan Funds or submit the reports timely. The key line items contain critical information and should reconcile to the Authority's financial documents and account balances. Cause: The current internal control system in place was not adequate to ensure: loan reporting procedures were followed in accordance with the RLF Plan approved by the EDA. Effect: The reports do not contain accurate information. This is a repeat finding of 2023-001. Recommendation: We have the following recommendations: 1) the Authority should implement procedures to ensure that the RLF program is administered in accordance with the plan approved by the EDA, 2) the Authority should implement procedures to ensure that required reports are reviewed for accuracy prior to being submitted by the due date. View of Responsible Official: Management agrees with the finding. See separate corrective action plan.
Finding 2024-001 Reporting Criteria: Pursuant to 2 CFR section 200.303(a), the nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Revolving Loan Fund (RLF) recipients must administer RLFs in accordance with an RLF Plan approved by EDA. Pursuant to 13 CFR 307.14 (a) All RLF Recipients, including those receiving Recapitalization Grants for existing RLFs, must complete and submit an RLF report, using Form ED-209, in a format and at a frequency as required by EDA. Pursuant to 13 CFR 307.14 (b) All RLF Recipients must certify as part of the RLF report to EDA that the RLF is operating in accordance with the applicable RLF Plan and that the information provided is complete and accurate. Condition: There were no adequate internal controls to identify and correct material misstatements in key line items in the Form ED-209, Revolving Loan Fund Financial Report (report) for the Legacy or Cares Revolving Loan Funds or submit the reports timely. The key line items contain critical information and should reconcile to the Authority's financial documents and account balances. Cause: The current internal control system in place was not adequate to ensure: loan reporting procedures were followed in accordance with the RLF Plan approved by the EDA. Effect: The reports do not contain accurate information. This is a repeat finding of 2023-001. Recommendation: We have the following recommendations: 1) the Authority should implement procedures to ensure that the RLF program is administered in accordance with the plan approved by the EDA, 2) the Authority should implement procedures to ensure that required reports are reviewed for accuracy prior to being submitted by the due date. View of Responsible Official: Management agrees with the finding. See separate corrective action plan.
Finding 2024.001: Eligibility - Significant Deficiency Grantor: U.S. Department of Agriculture Federal Program Names: WIC Special Supplemental Nutrition Program for Women, Infants and Children Federal Assistance Listing Numbers: 10.557 Federal Award Identification Number and Year: 79194 - 2023, 76709 - 2023 and 88458 - 2024 Name of Pass-through Entity: Indiana State Department of Health Criteria In accordance with 2CFR 200.303(a), Internal Controls, a nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The specific eligibility requirements are unique to each federal program, in accordance with the terms and conditions of the Federal award pertaining to the program. Condition During our testing over eligibility requirements, we were unable to review sufficient documentation to support that benefit recipients were eligible for benefits. Cause The Center's internal controls over eligibility were not consistently followed to ensure the presence of documentation to support that all benefit recipients were eligible for benefits. Effect Lack of sufficient support over eligibility could result in ineligible individuals receiving benefits. Questioned Costs None. Context We selected 40 beneficiaries charged to the federal program to test compliance and controls over eligibility. Out of 40 individuals tested, we noted 4 instances where there was no documentation to support that the benefit recipients were eligible for benefits and the internal controls over eligibility were followed. Identification of Repeat Finding None. Recommendation We recommend that management provide training to those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Views of Responsible Officials Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.
Department of Transportation Federal Financial Assistance Listing 20.106; Awards AIP3-46-0050-59, AIP3-46-0050-62, AIP3-46-0050-63, and AIP3-46-0050-64. COVID-19 Airport Improvement Program Reporting Material Weakness in Internal Control over Compliance; Material Noncompliance Criteria - 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal controls over the federal awards that provide assurance that the entity is managing the federal awards in compliance with federal statutes, regulations, and the conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with the program requirements. Condition - The SF-425 annual report dated September 30, 2024, for award AIP3-46-0050-64 underreported the federal share of expenditures by $23,588, while the FAA Form 5100-127 annual report dated December 31, 2023, for all awards underreported the total capital expenditures and construction in progress by $2,729,962. Cause - The Authority does not have an internal control structure designed to ensure amounts reported on SF-425 and FAA Form 5100-127 reports are adequately reviewed and agree to underlying accounting records. Effect - Lack of compliance with designed internal controls over reporting could result in the Authority reporting incorrect or incomplete information. Questioned Costs - None reported. Context/Sampling - A nonstatistical sample of 7 reports out of 27 reports. Repeat Finding from Prior Year – Yes, prior year finding 2023-002 Recommendation - Management should determine and formalize reporting responsibilities between the Airport and the State and establish review processes to ensure that amounts included in SF-425 and FAA Form 5100-127 reports agree with the underlying accounting records. Views of Responsible Officials - Management agrees with the finding.
Department of Transportation Federal Financial Assistance Listing 20.106; Awards AIP3-46-0050-59, AIP3-46-0050-62, AIP3-46-0050-63, and AIP3-46-0050-64. COVID-19 Airport Improvement Program Reporting Material Weakness in Internal Control over Compliance; Material Noncompliance Criteria - 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal controls over the federal awards that provide assurance that the entity is managing the federal awards in compliance with federal statutes, regulations, and the conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with the program requirements. Condition - The SF-425 annual report dated September 30, 2024, for award AIP3-46-0050-64 underreported the federal share of expenditures by $23,588, while the FAA Form 5100-127 annual report dated December 31, 2023, for all awards underreported the total capital expenditures and construction in progress by $2,729,962. Cause - The Authority does not have an internal control structure designed to ensure amounts reported on SF-425 and FAA Form 5100-127 reports are adequately reviewed and agree to underlying accounting records. Effect - Lack of compliance with designed internal controls over reporting could result in the Authority reporting incorrect or incomplete information. Questioned Costs - None reported. Context/Sampling - A nonstatistical sample of 7 reports out of 27 reports. Repeat Finding from Prior Year – Yes, prior year finding 2023-002 Recommendation - Management should determine and formalize reporting responsibilities between the Airport and the State and establish review processes to ensure that amounts included in SF-425 and FAA Form 5100-127 reports agree with the underlying accounting records. Views of Responsible Officials - Management agrees with the finding.
Department of Transportation Federal Financial Assistance Listing 20.106; Awards AIP3-46-0050-59, AIP3-46-0050-62, AIP3-46-0050-63, and AIP3-46-0050-64. COVID-19 Airport Improvement Program Reporting Material Weakness in Internal Control over Compliance; Material Noncompliance Criteria - 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal controls over the federal awards that provide assurance that the entity is managing the federal awards in compliance with federal statutes, regulations, and the conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with the program requirements. Condition - The SF-425 annual report dated September 30, 2024, for award AIP3-46-0050-64 underreported the federal share of expenditures by $23,588, while the FAA Form 5100-127 annual report dated December 31, 2023, for all awards underreported the total capital expenditures and construction in progress by $2,729,962. Cause - The Authority does not have an internal control structure designed to ensure amounts reported on SF-425 and FAA Form 5100-127 reports are adequately reviewed and agree to underlying accounting records. Effect - Lack of compliance with designed internal controls over reporting could result in the Authority reporting incorrect or incomplete information. Questioned Costs - None reported. Context/Sampling - A nonstatistical sample of 7 reports out of 27 reports. Repeat Finding from Prior Year – Yes, prior year finding 2023-002 Recommendation - Management should determine and formalize reporting responsibilities between the Airport and the State and establish review processes to ensure that amounts included in SF-425 and FAA Form 5100-127 reports agree with the underlying accounting records. Views of Responsible Officials - Management agrees with the finding.
Department of Transportation Federal Financial Assistance Listing 20.106; Awards AIP3-46-0050-59, AIP3-46-0050-62, AIP3-46-0050-63, and AIP3-46-0050-64. COVID-19 Airport Improvement Program Reporting Material Weakness in Internal Control over Compliance; Material Noncompliance Criteria - 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal controls over the federal awards that provide assurance that the entity is managing the federal awards in compliance with federal statutes, regulations, and the conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with the program requirements. Condition - The SF-425 annual report dated September 30, 2024, for award AIP3-46-0050-64 underreported the federal share of expenditures by $23,588, while the FAA Form 5100-127 annual report dated December 31, 2023, for all awards underreported the total capital expenditures and construction in progress by $2,729,962. Cause - The Authority does not have an internal control structure designed to ensure amounts reported on SF-425 and FAA Form 5100-127 reports are adequately reviewed and agree to underlying accounting records. Effect - Lack of compliance with designed internal controls over reporting could result in the Authority reporting incorrect or incomplete information. Questioned Costs - None reported. Context/Sampling - A nonstatistical sample of 7 reports out of 27 reports. Repeat Finding from Prior Year – Yes, prior year finding 2023-002 Recommendation - Management should determine and formalize reporting responsibilities between the Airport and the State and establish review processes to ensure that amounts included in SF-425 and FAA Form 5100-127 reports agree with the underlying accounting records. Views of Responsible Officials - Management agrees with the finding.
Criteria: 2 CFR 200.303(a) and 45 CFR 1635 establishes that recipients must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. One of the Organization’s internal controls for ensuring such compliance is that each employee’s supervisor reviews and approves all time and attendance reports. Condition: During our audit we noted one timesheet out of a sample of 40 that did not have documentation of review by the employee’s supervisor. Cause: There was a lapse in the internal control process to ensure documentation of timely and proper review of timesheets. Effect: Lack of timesheet review by a supervisor who is familiar with a given employee’s responsibilities could result in charges to federal awards that are in excess of what was actually earned, or incorrect allocations of expenditures to various awards. Questioned Costs: None Recommendation: We recommend the Organization review payroll policies and procedures with applicable employees to ensure compliance with documented procedures.
Reference Number 2024-001 – Finding of Noncompliance Federal Award Information - Research and Development Cluster (“R&D”) – Various ALN# Federal Award Agency - Department of Energy (“DOE”) Compliance Requirement - Special Tests and Provisions (Publications) Criteria- Per the DOE Award Special Terms and Conditions, the Institute is required to include an acknowledgement of the DOE award and legal disclaimer within all publications arising out of, or relating to, work performed under the award, whether copyrighted or not. Further, 2 CFR section 200.303 requires that non-Federal entities 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 statues, regulations, and the terms and conditions of the Federal award. Condition- For the fiscal year ended December 31, 2024, there were publications released with reference to research and development project activities funded by DOE that did not include the required legal disclaimer and (or) acknowledgement statement in pursuant with DOE grant contractual provisions. Cause - Although the publication requirement was internally acknowledged at the beginning of the execution of these grant awards, there is a lack of internal control established to formalize and streamline review of publications throughout the life cycle of each applicable project. Effect - Failure to establish effective internal reviews and monitoring over publications published throughout project periods could potentially result in undetected noncompliance, exposing the Institute to consequences from regulatory agencies. Questioned Costs - Not applicable Context or Perspective - The quality of internal review was compromised due to the involvement of multiple parties executing separate review process, compounded by time constraints before the release of the information. 3 out of 40 publications (total sample size) were identified as noncompliance. Among these 3 publications, 2 included the acknowledgement but not the legal disclaimer, and 1 lacked both mandatory statements. Overall, the identified instances of noncompliance are deemed to be isolated to special circumstances when publications require collaborative reviews between the Institute and external parties. New or Repeat Finding - New Finding Recommendation: We recommend the Institute establish formal procedures to ensure a thorough and effective review for each publication prior to its public release. View of Responsible Officials - See attached corrective action plan.
Reference Number 2024-001 – Finding of Noncompliance Federal Award Information - Research and Development Cluster (“R&D”) – Various ALN# Federal Award Agency - Department of Energy (“DOE”) Compliance Requirement - Special Tests and Provisions (Publications) Criteria- Per the DOE Award Special Terms and Conditions, the Institute is required to include an acknowledgement of the DOE award and legal disclaimer within all publications arising out of, or relating to, work performed under the award, whether copyrighted or not. Further, 2 CFR section 200.303 requires that non-Federal entities 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 statues, regulations, and the terms and conditions of the Federal award. Condition- For the fiscal year ended December 31, 2024, there were publications released with reference to research and development project activities funded by DOE that did not include the required legal disclaimer and (or) acknowledgement statement in pursuant with DOE grant contractual provisions. Cause - Although the publication requirement was internally acknowledged at the beginning of the execution of these grant awards, there is a lack of internal control established to formalize and streamline review of publications throughout the life cycle of each applicable project. Effect - Failure to establish effective internal reviews and monitoring over publications published throughout project periods could potentially result in undetected noncompliance, exposing the Institute to consequences from regulatory agencies. Questioned Costs - Not applicable Context or Perspective - The quality of internal review was compromised due to the involvement of multiple parties executing separate review process, compounded by time constraints before the release of the information. 3 out of 40 publications (total sample size) were identified as noncompliance. Among these 3 publications, 2 included the acknowledgement but not the legal disclaimer, and 1 lacked both mandatory statements. Overall, the identified instances of noncompliance are deemed to be isolated to special circumstances when publications require collaborative reviews between the Institute and external parties. New or Repeat Finding - New Finding Recommendation: We recommend the Institute establish formal procedures to ensure a thorough and effective review for each publication prior to its public release. View of Responsible Officials - See attached corrective action plan.
Failure to Maintain Complete Accounting Records for Federal Awards. Criteria: Title 2 U.S. Code of Federal Regulations (CFR) Section 200.303 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires that the Village establish and maintain internal control over federal awards that provide reasonable assurance that the Village is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal award. One of the objectives of internal control over compliance is to ensure that federal transactions are properly recorded and accounted for in order to permit the preparation of reliable financial statements, including the Schedule of Expenditures of Federal Awards. Condition: Expenditures from federal grant revenue were not recorded in the Village’s accounting records and there were several posting errors related to the recording of the federal grant revenue.Cause: Oversight. Effect: Federal award transactions could possibly be excluded from the financial statements and the Schedule of Expenditures of Federal Awards. Recommendation: All future federal award revenue and expenditures should be recorded as transactions of the Water System Enterprise Fund in the accounting software. Management’s Response: The accounting records for the federal award revenues and expenditures have been properly maintained for calendar year 2025.
Assistance Listing, Federal Agency, and Program Name - ALN 21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) Federal Award Identification Number and Year - FAIN not available, 2022 Pass-through Entity - N/A - Direct funded Finding Type - Material weakness Repeat Finding - No Criteria - Per 2 CFR 200.303(a), nonfederal entities must establish and maintain effective intenral control over the federal award that provides resonable 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. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government issued by the Comptroller General of the United States or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The Township did not have controls in place surrounding the review of annual performance reporting. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not Applicable If questioned costs are not determinable, description of why known questioned costs were undetermined or otherwise could not be reported - Not Applicable Context - As the Township recieved less than $10 million of CSLFRF funding, the Township is required to submit an annual report for the program and have controls in place to ensure the report is filed on time and no errors in reporting occur. Cause and Effect - During the review of internal controls over the annual performance report required by the program, it was noted that there was no secondary review of the annual report before or after submission however, the report was filed on time and no errors in reporting were noted as a result of our audit procedures. Recommendation - In order to ensure reporting requirements are met and that reports are accurate, we recommend the Township incorporate a formal review process of the annual report. Views of Responsible Officials and Corrective Action Plan - The Township has implemented a formal review process within the Finance and Budget Department to ensure the integrity of annual performance reporting. One staff member has been designated to compile and complete the performance reports, while a separate finance team member is responsible for conducting an independent review prior to submission. To support this process, an internal timeline has been established to allow sufficient time for thorough review and validation of all performance data before final submission.
Finding 2024-001: Considered a material weakness in internal controls over major program compliance. Major Program ALN: 14.155 Major Program Name: Mortgage Insurance for the Purchase of Refinancing of Multifamily Housing Projects Criteria: According to 2 CFR Part 200 (Uniform Guidance), specifically 2 CFR §200.303, non-federal entities are required to establish and maintain effective internal control over federal awards. This includes written policies and procedures to ensure compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: During our review of Caspian Housing Corporation’s administration of its major federal program, we noted that the entity lacks formal, written policies and procedures governing key compliance areas. The absence of such written policies and procedures increases the risk of noncompliance with HUD program requirements and may result in inefficiencies, errors, or potential misuse of federal funds. Cause: Caspian Housing Corporation has not developed or implemented written policies and procedures in accordance with federal requirements. Effect: Without documented policies and procedures, Caspian Housing Corporation is at risk of noncompliance with federal requirements, which could lead to financial penalties, questioned costs, or potential loss of federal funding. Recommendation: We recommend that Caspian Housing Corporation develop and implement comprehensive written policies and procedures that align with Uniform Guidance requirements. Management Response: Management is in agreement with the recommendations and will work to implement the required policies and procedures in accordance with Uniform Guidance requirements during 2025. Auditor Non-compliance Code: S - internal control deficiencies
2024-001— Federal Supplemental Educational Opportunity Grants Eligibility U.S. Department of Education Student Financial Assistance Programs Cluster Federal Supplemental Educational Opportunity Grants (84.007) Federal Award Year: 2024-2025 Repeat Finding: No Criteria The Code of Federal Regulations (34 CFR 676.21(a)) requires that the Federal Supplemental Educational Opportunity Grants (FSEOG) program provides grants to eligible undergraduate students who have not previously earned a bachelor’s or first professional degree. Priority is given to Federal Pell Grant Program recipients who have the lowest Expected Family Contribution (EFC). The Code of Federal Regulations (2 CFR 200.303) requires entities receiving Federal awards establish and maintain internal controls deigned to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should include procedures in place to ensure accurate awarding of FSEOG funds. Condition The University did not properly award FSEOG funds to one student. Out of the 40 students tested, we noted one student (2.5%) who was eligible to receive the funds during the award period and was not awarded the funds. The University’s internal control activities did not properly identify and correct this compliance finding above. Cause During the packaging process, an employee of the University incorrectly cancelled the award to the student. Effect Noncompliance with federal regulations could result in heightened monitoring by the U.S. Department of Education. Context We tested 40 students who received FSEOG funds. For each student tested, management provided documentation showing the student’s Cost of Attendance (COA), EFC, and awards granted to each student. Out of the 40 students tested, we noted one student (2.5%) who was eligible to receive the FSEOG funds during the award period and was not awarded the funds. Questioned costs There were no questioned costs with respect to this finding. Recommendation We recommend that the College review current processes and controls in place in order to ensure that future student financial assistance is properly awarded. Views of responsible officials Management agrees with this finding. See corrective action plan.
2024-002— Federal Pell Grant Program Eligibility U.S. Department of Education Student Financial Assistance Programs Cluster Federal Pell Grant Program (84.063) Federal Award Year: 2023-2024 Repeat Finding: No Criteria The Code of Federal Regulations (34 CFR 690) requires that the University provides Federal Pell Grant Program funds to eligible students enrolled in eligible undergraduate programs and certain eligible post-baccalaureate teacher certificate programs The Code of Federal Regulations (2 CFR 200.303) requires entities receiving Federal awards establish and maintain internal controls deigned to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should include procedures in place to ensure accurate awarding of Federal Pell Grant Program funds. Condition The University did not properly award Federal Pell Grant Program funds to one student. Out of the 40 students tested, we noted one student (2.5%) who was eligible to receive the funds during the award period and was not awarded the funds. The University’s internal control activities did not properly identify and correct this compliance finding above. Cause During the re-packaging process performed by the University when the student returned to active status, an employee of the University incorrectly did not award the funds for the spring 2024 term. Effect Noncompliance with federal regulations could result in heightened monitoring by the U.S. Department of Education. Context We tested 40 students who received Federal Pell Grant Program funds. For each student tested, management provided documentation showing the student’s Cost of Attendance (COA), EFC, and awards granted to each student. Out of the 40 students tested, we noted one student (2.5%) who was eligible to receive the Federal Pell Grant Program funds during the award period and was not awarded the correct amount of these funds. Questioned costs There were no questioned costs with respect to this finding. Recommendation We recommend that the College review current processes and controls in place in order to ensure that future student financial assistance is properly awarded. Views of responsible officials Management agrees with this finding. See corrective action plan.
FINDING 2024-001 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Federal Agency: Department of the Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listings Number: 21.027 Federal Award Numbers and Years (or Other Identifying Numbers): 22-004-WM, FY2024 Compliance Requirement: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Modified Opinion Repeat Finding This is a repeat finding from the immediately prior audit report. The prior audit finding number was 2023-002. Condition and Context Prior to entering into subawards and covered transactions with COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (SLFRF) award funds, recipients are required to verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded. "Covered transactions" include, but are not limited to, contracts for goods and services awarded under a nonprocurement transaction (i.e., grant agreement) that are expected to equal or exceed $25,000. The verification is done by checking the Excluded Parties List System (EPLS), collecting a certification from that vendor, or adding a clause or condition to the covered transaction with that vendor. The Town's policies related to SLFRF suspension and debarment requirements included a clause or condition added to covered transactions expected to equal or exceed $25,000 with that vendor. Two vendors were identified as having transactions that equaled or exceeded $25,000. The two vendors, with total expenditures of $2,572,459.27, were reviewed. For both vendors, the Town did not have documented evidence that the clause was included in the contract with the vendor nor that any other methods were employed to verify the vendor was not suspended, debarred, or otherwise excluded prior to entering into the transactions. The lack of internal controls and noncompliance were systematic issues throughout the audit period. Criteria 2 CFR 200.303 states in part: "The non-Federal entity must: INDIANA STATE BOARD OF ACCOUNTS 14 TOWN OF BROWNSBURG SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) (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. These internal controls should be in compliance with guidance in 'Standards for Internal Control in the Federal Government' issued by the Comptroller General of the United States or the 'Internal Control Integrated Framework', issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). . . ." 31 CFR 19.300 states: "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you do business is not excluded or disqualified. You do this by: (a) Checking the EPLS; or (b) Collecting a certification from that person if allowed by this rule; or (c) Adding a clause or condition to the covered transaction with that person." Cause The Town was unable to provide documentation to demonstrate they included a clause in contracts or otherwise verified contractors were not suspended, debarred, or otherwise excluded prior to entering into the transaction. Upon inquiry, the Town did not amend the prior contracts to include the language required. Effect Without the proper implementation of an effectively designed system of internal controls, the Town cannot ensure the vendors paid with federal funds are eligible to participate in federal programs. Any program funds the Town used to pay vendors that have been suspended or debarred would be unallowable. Noncompliance with the provisions of federal statutes, regulations, and the terms and conditions of the federal award could result in the loss of future funding to the Town. Questioned Costs There were no questioned costs identified. Recommendation We recommended that management of the Town establish a proper system of internal controls and develop policies and procedures to ensure contractors and subrecipients, as appropriate, are not suspended, debarred, or otherwise excluded prior to entering into contracts or subawards and document reasons for vendors that are chosen without adhering to formal procurement methods. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.
FINDING 2024-002 Subject: Drinking Water State Revolving Fund - Procurement and Suspension and Debarment Federal Agency: Environmental Protection Agency Federal Program: Drinking Water State Revolving Fund Assistance Listings Number: 66.468 Federal Award Number and Year (or Other Identifying Numbers): DW23103203 Compliance Requirement: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Modified Opinion Condition and Context Prior to entering into subawards and covered transactions with Drinking Water State Revolving Fund (DWSRF) award funds, recipients are required to verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded. "Covered transactions" include, but are not limited to, contracts for goods and services awarded under a nonprocurement transaction (i.e., grant agreement) that are expected to equal or exceed $25,000. The verification is done by checking the Excluded Parties List System (EPLS), collecting a certification from that vendor, or adding a clause or condition to the covered transaction with that vendor. The Town's policies related to DWSRF suspension and debarment requirements included a clause or condition added to covered transactions expected to equal or exceed $25,000 with that vendor. One vendor was identified as having transactions that equaled or exceeded $25,000. The one vendor, with total expenditures of $1,120,029, was reviewed. For this vendor, the Town did not have documented evidence that the clause was included in the contract with the vendor nor that any other methods were employed to verify the vendor was not suspended, debarred, or other excluded prior to entering into the transactions. The lack of internal controls and noncompliance were systematic issues throughout the audit period. Criteria 2 CFR 200.303 states in part: "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. These internal controls should be in compliance with guidance in 'Standards for Internal Control in the Federal Government' issued by the Comptroller General of the United States or the 'Internal Control Integrated Framework', issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). . . ." 2 CFR 180.300 states: "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified. You do this by: INDIANA STATE BOARD OF ACCOUNTS 16 TOWN OF BROWNSBURG SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) (a) Checking SAM Exclusions; or (b) Collecting a certification from that person; or (c) Adding a clause or condition to the covered transaction with that person." Cause The Town was unable to provide documentation to demonstrate they included a clause in contracts or otherwise verified contractors were not suspended, debarred, or otherwise excluded, prior to entering into the transaction. Upon inquiry, the Town did not amend the prior contracts to include the language required. Effect Without the proper implementation of an effectively designed system of internal controls, the Town cannot ensure the vendors paid with federal funds are eligible to participate in federal programs. Any program funds the Town used to pay vendors that have been suspended or debarred would be unallowable. Noncompliance with the provisions of federal statutes, regulations, and the terms and conditions of the federal award could result in the loss of future funding to the Town. Questioned Costs There were no questioned costs identified. Recommendation We recommended that management of the Town establish a proper system of internal controls and develop policies and procedures to ensure contractors and subrecipients, as appropriate, are not suspended, debarred, or otherwise excluded prior to entering into contracts or subawards and document reasons for vendors that are chosen without adhering to formal procurement methods. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Significant deficiency in internal controls over allowable costs. Federal Agencies: Department of Defense; United States Department of Health and Human Services Assistance Listing Numbers: 12.420, 12.750, 93.865 Assistance Listing Names: Military Medical Research and Development; Uniformed Services University Medical Research Projects; Child Health and Human Development Extramural Research Award Numbers: HU00012020011; HU00012120093; 5938; W81XWH-22-1-0519; HU00012320049; HU00012320068; HU00012320090; HU00012420044; HU00012320120; 67420; HU00012320060 Period of Award: Various Criteria Per standards contained in Title 2 U.S. Code of Federal Regulations (CFR) Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart D ‐ Post Federal Award Requirements, Section 200.303, a 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. Condition/Context During testing over allowable costs, out of 25 nonpayroll transactions tested, 3 transactions were related to facility lease costs which were recovered from the Federal award at a higher rental rate than was identified in the underlying lease agreement resulting in an over recovery of costs of $16,033. Upon further testing, we identified total over recovery of facility lease costs of $94,529 to Federal awards during calendar year 2024 as a result of costing errors related to this particular lease agreement. Cause The Foundation had renegotiated the facility lease at a lower rental rate. Due to an administrative oversight, lease costs continued to be recovered from Federal awards at the previous rental rate. The Foundation’s internal controls over compliance were not operating effectively to detect the over recovery of costs. Effect or Potential Effect Lack of adequate internal controls resulted in lease costs being over recovered from Federal awards. Questioned Costs $94,529 Repeat Finding This is not a repeat finding. Recommendation We recommend the Foundation improve the operation of internal controls over compliance to ensure costs charged to Federal awards are properly reviewed. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
2024-001 – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) (Significant Deficiency) Criteria: According to 2 CFR 200.210(b), a recipient of Federal awards is required to prepare a SEFA for the period covered by the entity’s financial statement which must include the total Federal awards expended. In addition, 2 CFR 200.303 requires non-Federal entities to, among other things, establish, document, and maintain effective internal control over 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. Effective internal controls should include procedures to ensure expenditures are properly reported on the SEFA. In addition to providing an accurate SEFA, an organization must also be able to demonstrate that it has a system of internal control that supports the preparation of the SEFA. Condition: The University did not have an adequate process in place to prepare and review its SEFA. Cause: The University’s internal control process for preparing the SEFA did not include review and approval of the SEFA prior to providing it to the auditor. Effect: Failure to accurately report federal expenditures on the SEFA could result in noncompliance with federal regulations. Recommendation: We recommend the University establish, document, and maintain effective internal controls over the preparation of the SEFA. At a minimum, an organization should be able to show documentation that the SEFA was reviewed and approved by an individual who was not directly involved with the initial preparation of the SEFA. The review process should include checking both the reported expenditures of federal awards and the assistance listing numbers reported for each grant program. Action Taken: Management has put in place the following procedures: We will establish, document and maintain effective internal control over Federal awards by performing reconciliation of federal funds at the end of each trimester. The account reconciled will be listed on the SEFA. The Director of Financial Aid will be responsible for preparing the SEFA. It will be reviewed and re-reconciled by the Business Systems Analyst and the FA Asst. Director. Reports used to reconcile come from our Sonis system and are the Award Summary Detail and the Charges and Credits reports. Responsible Party and contact information: Valerie Souza, FA Business Systems Analyst and Lynda Swanson, Asst. Director of Financial Aid. Expected Date of Correction: At the end of each trimester. Full completion of processes will be at the end of our fiscal year/calendar year when audit preparation begins.
Assistance Listing, Federal Agency, and Program Name Assistance Listing Number 11.463, National Oceanic and Atmospheric Administration, Habitat Conservation Federal Award Identification Number and Year NA18NMF4630004 Pass through Entity National Fish and Wildlife Foundation Finding Type Material weakness Repeat Finding No Criteria Per 2 CFR 200.303(a), the nonfederal entity must establish and maintain effective internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. These internal controls should be in compliance with the guidance in the "Standards for Internal Control in the Federal Government," issued by the Comptroller General of the United States, or the "Internal Control Integrated Framework," issued by the Committee of Sponsoring Organization of the Treadway Commission (COSO). Condition The Road Commission did not have the appropriate processes and controls in place to ensure that reporting dates and period of performance deadlines were identified, to ensure that reporting and reimbursement requests were appropriately reviewed, or to ensure that vendors were reviewed for suspension and debarment prior to contracts being entered into. Questioned Costs None If questioned costs are not determinable, description of why known questioned costs were undetermined or otherwise could not be reported N/A Identification of How Questioned Costs Were Computed N/A Context During testing of required reporting, as well as reimbursement requests submitted, it was noted that there was no evidence of supervisory reviews prior to submission of these documents. During testing of selected contracts, it was also noted that there was no evidence of review for suspension and debarment prior to entering into contracts. Additionally, while the Road Commission ultimately received extensions for reporting and the period of performance on this grant agreement, these did not occur until after the original dates for both had passed. Cause and Effect If extensions had not been received for reporting and period of performance deadlines, this lack of control could have resulted in instances of noncompliance. Additionally, the lack of appropriate reviews of reporting, requests for reimbursement, and reviews of vendors for suspension and debarment could have resulted in instances of noncompliance. Recommendation The Road Commission should review its processes and controls in these areas to ensure that they are aware of all reporting and period of performance deadlines, that all reporting and reimbursement requests are appropriately reviewed, and that all vendors for spending utilizing federal funding are reviewed for suspension and debarment. Views of Responsible Officials and Corrective Action Plan The federal grant was awarded to the Road Commission of Kalamazoo County (RCKC) in 2021 with most of the project being completed in 2024. The project will be finalized in 2025. Although deadline extensions were received for the Interim Programmatic Report and Final Report, they were not requested in advance of the deadlines. Effective immediately, the Project Engineer and Assistant County Engineer will track and manage all federal grant deadlines in their Outlook calendars to avoid risk of non-compliance. The federal agency for this grant would only provide one user with system access to submit reimbursement requests, and RCKC granted this access to the Project Engineer. The Accountant tracked cost accumulation on the grant project, provided the general ledger detail to the Project Engineer and confirmed reimbursement requests would be submitted. However, there was no review and approval of the individual reimbursement requests. Effective immediately, additional reimbursement requests for this grant will be reviewed and approved by the Assistant County Engineer and Finance prior to submitting through the system for reimbursement. For future federal grants, cost reimbursement system access will only be granted to Finance. The Accountant will review the general ledger for active federal projects monthly and submit the general ledger detail to Engineering for review and approval per contract terms. Once Engineering approves, the Finance Director will review and approve prior to the Accountant submitting the request to avoid risk of non-compliance. Vendors were not reviewed for suspension and debarment prior to entering into the contracts. Effective immediately, the SAM.gov website will be utilized to confirm vendors are active and not suspended or debarred from federal work prior to entering into contracts to avoid risk of non-compliance.
Transparency Act Reporting; Identification of the Federal Program Federal Agency and Program Name Assistance Listing # U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA); Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC); 93.912 Award Year(s): July 1, 2023–June 30, 2025; September 1, 2023–August 31, 2025 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act) that are codified in 2 CFR Part 170, “unless the auditee is exempt as provided in paragraph d. of this award term, the auditee must report each action that equals or exceeds $30,000 in Federal funds for a subaward to a non-Federal entity or Federal agency no later than the end of the month following the month in which the obligation was made.” 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) per submission instructions posted at http://www.fsrs.gov. Condition: During our audit, we noted six instances where the required Federal Funding Accountability and Transparency Act (FFATA) reports were not submitted in the FSRS in FY 2024. Cause: Management did not have sufficient internal controls to ensure that the required FFATA reports were submitted with all the correct information. Effect or Potential Effect: Sanford did not submit the necessary FFATA report under the RHC project for each first-tier subaward agreement or modifications over $30,000 in FSRS and consequently was not in compliance with the requirements under the Transparency Act. Questioned Costs: $0 Context: Under the RHC program, there were four subrecipients that had a total of six subaward modifications in FY 2024. The six subaward modifications for which FFATA reports were not submitted totaled $388,722. Total subrecipient’s costs are $513,334 in FY 2024. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend management strengthen its internal controls and procedures over the review of subrecipient awards and amendments to ensure the required FFATA reports are submitted to be in compliance with the Federal Transparency Act. Views of Responsible Officials: As it relates to the Federal Funding Accountability and Transparency Act (FFATA) reporting, Sanford has revised procedures to provide further clarity on FFATA reporting. There is an additional requirement to include the FFATA report as an attachment to the subrecipient monitoring form, and this will be monitored through the monthly internal review conducted on subrecipient risk assessment and monitoring status.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.