Criteria: HUD’s Continuum of Care program (ALN 14.267) requires that participant annual income be determined using gross income in accordance with 24 CFR § 5.609 and 24 CFR § 5.611, and that such determinations be supported by adequate and verifiable source documentation. Recipients are required to maintain complete and accurate participant files, including signed income certifications, zero-income affidavits where applicable, and sufficient third-party or source documentation (e.g., pay stubs) to support income calculations. In accordance with 2 CFR § 200.303, organizations must establish and maintain effective internal controls over compliance to ensure that income determinations and rent calculations are accurate, complete, and properly documented. Conditions: Our testing of 18 tenant files identified deficiencies in income documentation and rent calculation support. Specifically, 2 tenant files lacked documented zero-income verification, 2 files contained insufficient supporting pay documentation, 1 file was missing a signed income certification, and in 2 instances rent calculations were based on net wages rather than gross wages. These results indicate that controls over income verification and rent calculation documentation are not consistently operating effectively. Cause and Effect: This condition appears to be due to inconsistent application of documentation requirements and the absence of a formalized review process to ensure completeness and accuracy of income determinations and rent calculations. We identified a significant deficiency in internal control over compliance related to income verification and rent calculation documentation. While rent calculations appeared reasonable based on available information and no questioned costs were identified, the control deficiencies increase the risk that errors or noncompliance could occur and not be detected in a timely manner. Recommendations: We recommend management enhance controls over income verification and rent calculation documentation by implementing standardized documentation requirements and file checklists to ensure all required support (e.g., pay stubs, zero-income affidavits, and calculation worksheets) is obtained and retained prior to approval of assistance. Additionally, a secondary review should be performed and documented to verify the completeness and accuracy of income determinations and rent calculations.
Criteria: HUD’s Continuum of Care program (ALN 14.267) requires that rental assistance payments comply with rent reasonableness requirements in accordance with 24 CFR § 578.49. Rent reasonableness must be determined and documented prior to execution of the lease and before assistance is provided, and must be based on accurate lease terms, unit characteristics, and comparable market data. Additionally, participant income used in determining rent contributions must be calculated in accordance with 24 CFR § 5.609 and 24 CFR § 5.611. In accordance with 2 CFR § 200.303, organizations are required to establish and maintain effective internal controls over compliance to ensure that rent determinations are accurate, properly supported, and performed in a timely manner. Conditions: Our testing of 18 tenant files identified deficiencies in the timeliness and accuracy of rent reasonableness determinations. Specifically, in 4 instances, rent reasonableness calculations were performed after lease execution, and in 5 instances, the calculations were based on incorrect lease amounts. These results indicate that controls over the timeliness and accuracy of rent reasonableness determinations are not consistently operating effectively. Cause and Effect: This condition appears to be due to inadequate internal controls and monitoring procedures to ensure that rent reasonableness determinations are completed prior to lease execution and that lease terms are verified for accuracy before performing the analysis. We identified a significant deficiency in internal control over compliance related to rent reasonableness determinations. The lack of timely and accurate determinations increases the risk that the program could approve rents that exceed market rates, resulting in potential noncompliance with program requirements and inefficient use of program funds. No questioned costs were identified as a result of this condition. Recommendations: We recommend management implement formal procedures requiring that rent reasonableness determinations are completed and documented prior to lease execution and approval of assistance. Management should establish standardized checklists or workflows to ensure rent reasonableness is performed as a required step before assistance is authorized. Additionally, staff should be trained on these procedures and the importance of timely compliance. A secondary review process should be implemented to verify lease terms, unit data, and calculation accuracy. Periodic supervisory reviews should also be conducted to ensure compliance with documentation and timing requirements.
Criteria: HUD’s Continuum of Care program (ALN 14.267) requires recipients to maintain complete and accurate documentation to support participant eligibility and rental assistance in accordance with 24 CFR §578.103. Tenant-based rental assistance must be supported by a valid lease between the participant and landlord in accordance with applicable housing requirements (including 24 CFR § 982.305 and 24 CFR §982.309, as applicable through program guidance). Required participant protections and disclosures, including those under the Violence Against Women Act (VAWA), must be provided and documented in accordance with 24 CFR § 5.2005 and 24 CFR § 5.2009. In addition, housing quality standards and environmental requirements, including inspections and lead-based paint disclosures, must be completed and documented prior to assistance in accordance with 24 CFR § 982.401 and 24 CFR § 35.92. Furthermore, in accordance with 2 CFR § 200.303, organizations must establish and maintain effective internal controls to ensure required documentation is obtained, reviewed, and retained prior to the disbursement of federal funds. Where utilities are paid as a supportive service under 24 CFR § 578.51, appropriate documentation, including participant consent, must be maintained. Conditions: Our testing of 18 tenant files identified multiple instances of missing or incomplete required documentation. Specifically, 1 file lacked an executed lease agreement, 3 files contained leases with terms less than one year, 2 files were missing required RAP forms with VAWA addenda, 1 file lacked inspection documentation, 1 file was missing a Form W-9, and 1 file did not include a required lead-based paint disclosure. Additionally, among 2 Permanent Supportive Housing tenant files tested, 1 file lacked a required Consent to Pay Utilities form. These results indicate that controls over required documentation are not consistently operating effectively. Cause and Effect: This condition appears to be due to inadequate internal controls and monitoring procedures to ensure that all required documentation is obtained, completed, and retained prior to the approval and disbursement of rental assistance. Specifically, staff did not consistently utilize a standardized checklist or review process to verify file completeness. We identified a significant deficiency in internal control over compliance related to required documentation. The absence of required documentation increases the risk of noncompliance with program requirements, potential disallowance of costs, and repayment of federal funds. No questioned costs were identified as a result of this condition. Recommendations: We recommend management strengthen controls over required documentation by implementing a standardized pre-approval checklist to ensure all required documentation is obtained and verified prior to disbursement of assistance. This should include, at a minimum, a fully executed lease (including verification of lease term), RAP agreement and VAWA documentation, inspection and housing quality documentation, Form W-9, and required lead-based paint disclosures. For supportive services such as utility payments, required participant consent documentation should be obtained and retained prior to payment. Additionally, management should implement a documented secondary review process and perform periodic quality control reviews to ensure ongoing compliance. Staff should be trained on documentation requirements and file completion standards.
Criteria: HUD’s Continuum of Care program (ALN 14.267) requires recipients to provide and document matching contributions in accordance with 24 CFR § 578.73. Recipients must maintain adequate records to support the source and allowability of match contributions in accordance with 24 CFR § 578.103. In addition, in accordance with 2 CFR § 200.303, organizations are required to establish and maintain effective internal controls over compliance, including appropriate segregation of duties and review procedures, to ensure that match calculations and supporting documentation are accurate, complete, and properly supported. Conditions: Our testing of 2 Permanent Supportive Housing tenant files related to matching requirements identified that, in both instances, match calculations and supporting documentation were not reviewed and approved by an individual independent of the preparer. These results indicate that controls over the review and approval of match documentation are not operating effectively. Cause and Effect: This condition appears to be due to inadequate segregation of duties and the absence of a formalized independent review process over match calculations and supporting documentation. We identified a significant deficiency in internal control over compliance related to the matching requirement. The lack of independent review increases the risk that errors or noncompliance in match reporting could occur and not be detected in a timely manner. Although no questioned costs or instances of noncompliance were identified as a result of our testing, this control is considered important to ensuring ongoing compliance with program requirements. Recommendations: We recommend management strengthen controls over match reporting by enhancing segregation of duties and implementing an independent review process for match calculations and supporting documentation. Where full segregation of duties is not feasible, compensating controls—such as documented supervisory review by an individual not involved in preparation—should be implemented. Management should also establish formal procedures and standardized checklists to ensure match contributions are properly supported, reviewed, and approved prior to reporting. Periodic monitoring procedures should be performed to ensure continued compliance.
United States Department of the Treasury Reference Number: 2024-010 Program: 21.027 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Federal Award Number: 51-6000255 Type of Finding: Noncompliance and Significant Deficiency in Internal Controls over Compliance Compliance Requirement: Reporting Condition: The following conditions were found during testing of the Town’s Annual Report for the period April 1, 2023 through March 31, 2024. 1. The Town’s procedures over the reporting did not include documentation of the preparation and review of the report. 2. Testing of the key line items- Obligations and Expenditures - Quantifiable Objective Criteria revealed the following: a. The Town reported the budgeted amount as cumulative obligations. b. The Town reported the same amount for current period obligations, current period expenditures and cumulative expenditures. The reported amount appeared to be the calculated amount of cumulative obligations. The support for the report did not appear to calculate the current period obligations or current period expenditures. A similar finding was reported in prior years’ audits. Criteria: United States Department of the Treasury State and Local Fiscal Recovery Funds Compliance and Reporting Guidance version 5.0 was issued September 20, 2022 and provides detailed reporting requirements 31 CFR §35.3 defines obligation and 2 CFR §200.1 defines expenditures. 2 CFR § 200.303 requires the implementation of effective internal controls: “Internal control requires the non-federal entity to 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 conditions of the federal award.” Cause: The Town experienced turnover at key positions in the Finance Department during the year. Effect: The Town was not in compliance with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) at 2 C.F.R. § 200.32 and the Guidance on Recipient Compliance and Reporting Responsibilities, issued by the U.S. Department of the Treasury. Recommendation: We recommend that the Finance Department enhance its processes and oversight surrounding grant financial reporting to ensure all required reports are completed accurately and timely. Views of Responsible Town Officials and Planned Corrective Actions: See corrective action plan. Responsible Positions: Town Manager and Director of Finance
Lack of Internal Controls over Substantially All Compliance Requirements Federal Agency: U.S. Department of Agriculture / U.S. Department of Education Federal Program: Child and Adult Care Food Program / Alaska Native Educational Programs ALN: 10.558 / 84.356A Award Numbers: 53301 / S356A210037 Type of Finding: Material weakness in internal control over compliance and material noncompliance. Criteria: Management is responsible for designing, implementing and maintaining internal controls relevant to ensuring that transactions charged to programs follow proper internal control processes (2 CFR Part 200 Subpart E §200.400 (d)). This includes ensuring there is proper supporting documentation for transactions as well as methods to document approval of the cost/activity to determine whether it is allowable under the funding requirements. Additionally, requirements relevant to maintaining effective internal control over Federal awards found in 2 CFR Part 200 Subpart E §200.303-Internal Controls are required to be implemented by grant recipients to provide reasonable assurance they are managing the award in compliance with Federal statutes, regulations, and the terms and conditions of the award. Condition and context: We were unable to obtain sufficient audit evidence to support compliance with applicable compliance requirements for all major federal programs of the Organization including Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Eligibility, Period of Performance, Procurement and Suspension and Debarment, Reporting and Special Tests and Provisions. The Organization was unable to provide supporting documentation for auditor’s to verify compliance with the compliance requirements listed above. Cause: Insufficient monitoring by management and the board over the financial and other activities of the Club as well as employee turnover in several positions contributed to an ineffective control environment throughout the Organization. Effect: Because adequate supporting documentation was not available for expenditures charged to the program, we could not determine whether the costs charged to the programs were allowable and in compliance with the applicable requirements. Accordingly, we consider the entire amount of expenditures for these programs during the audit period to be likely questioned costs. Questioned Costs: Likely questioned costs: Alaska Native Educational Program (ALN 84.356A) $757,173 and Child and Adult Care Food Program (ALN 10.558) $274,693 are equal to total estimated program expenditures during the period, representing the auditor’s best estimate of total questioned costs (likely questioned costs) for these major programs due to lack of adequate supporting documentation. Repeat finding: No, however due to the number of issues identified we believe this to be a systemic issue. Recommendation: We recommend that management implement a stronger internal controls environment that includes adequate staffing to maintain a segregation of duties for an effective control environment as well as improving monitoring processes to ensure the Organization is in compliance with requirements applicable to Federal statutes, regulations, and the terms and conditions of the award Management’s Response: Management concurs with the finding. See Corrective Action Plan.
Criteria or specific requirement: Per Uniform Guidance 2 CFR 200.329, recipients must submit performance reports as required by the Federal awarding agency and ensure such reports are accurate, complete, and submitted timely. Additionally, 2 CFR 200.303 requires the entity to establish and maintain effective internal controls over Federal awards, including controls that provide reasonable assurance that reporting requirements are met and that documentation is retained to support compliance. Condition: During testing of reporting, we noted the following: - Management stated that required reviews and approvals of performance reports were conducted in person, but the organization does not maintain documentation or an audit trail to evidence these reviews. While documentation was available for quarterly performance reports, 2 of 2 annual performance reports and 6 of 21 monthly performance reports tested lacked evidence of review and approval. - Additionally, 6 of 10 performance reports selected for testing were not submitted/uploaded timely in accordance with grantor requirements. Questioned costs: None Context: A control system to prevent and detect errors in the reporting process was not created at the time the reports were filed. Cause: The Organization has not established formalized policies and procedures governing the preparation, review, and timely submission of performance reports. As a result, responsibility for monitoring reporting deadlines and performing supervisory review was informal and not consistently documented. Effect: Failure to submit required performance reports timely increases the risk of noncompliance with federal award requirements and may result in adverse actions by the federal awarding agency, including delayed reimbursements or additional monitoring. Additionally, the lack of a documented review process increases the risk that performance reports may be incomplete, inaccurate, or not aligned with program requirements. Repeat finding: No Recommendation: We recommend the Organization develop and implement formal policies and procedures to ensure required performance reports are prepared, reviewed, and submitted in a timely manner. Such procedures should include clearly defined roles and responsibilities, tracking of reporting deadlines, and documented evidence of supervisory review and approval prior to submission. Views of responsible officials: There is no disagreement with the audit finding.
Criteria or specific requirement: Per Uniform Guidance 2 CFR 200.303, an entity is required to establish and maintain effective internal controls over Federal awards, including controls that provide reasonable assurance that reporting requirements are met and that documentation is retained to support compliance. Condition: During payroll testing, we noted for 2 of 60 payroll disbursements tested, the employee’s timecard was self‑approved by the individual whose time was being charged. There is no mitigating control in place to prevent or detect self‑approval of timecards or allocation of payroll costs. Questioned costs: None Context: At the time the timesheet was filed, there was no control system in place to prevent or detect such self-approval of timecards or allocation of payroll costs. The two instances noted were for the same employee and isolated to that specific employee. Cause: The Organization has not established formalized policies or supervisory procedures to prevent employees from self‑approving their own timecards. Effect: Self‑approval of timecards increases the risk of inaccurate or unsupported payroll charges, misallocation of labor costs, potential fraud or manipulation of reported hours, and reduced reliability of payroll and cost‑allocation data. Repeat finding: No Recommendation: We recommend the Organization develop and implement formal policies and procedures or workflow restrictions that prevent employees from self‑approving their own timecards. Views of responsible officials: There is no disagreement with the audit finding.
FINDING 2024-003 Subject: Highway Planning and Construction - Equipment and Real Property Management Federal Agency: Department of Transportation Federal Program: Highway Planning and Construction Assistance Listings Number: 20.205 Federal Award Number and Year (or Other Identifying Number): DES #9981680 Pass-Through Entity: Indiana Department of Transportation Compliance Requirement: Equipment and Real Property Management Audit Findings: Material Weakness, Modified Opinion Condition and Context A property record or capital asset listing is required to be maintained for all equipment, property improvements, and property purchased with the Highway Planning and Construction grant awards to ensure adequate safeguards are in place to prevent loss or damage of items. In addition, a complete physical inventory of the property must be taken every two years and reconciled with the detailed listing. The capital asset listing is to include a description of the property, a serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property. The County purchased $734,389 of right-of-way for the Veterans Memorial Trail project. The project had a 20 percent local match; thus, the Highway Planning and Construction grant portion was $587,511. The right-of-way purchase should have been recorded as capital assets purchased with 80 percent federal funding. However, the County did not include the right-of-way purchased in the capital asset listing. The lack of internal controls and noncompliance were isolated to DES #9981680. 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 200.313(d) states in part: "Management requirements. Procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, as a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of dunking for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. . . ." Cause Effective internal controls were not in place to ensure that all capital assets purchased with federal funds, including rights-of-ways, were added to the County's capital asset listing. Effect Noncompliance with the grant agreement and the compliance requirement could result in the repayment of federal funds. Questioned Costs There were no questioned costs identified. Recommendation We recommended that the County's management establish a proper system of internal controls that would ensure compliance with the Equipment and Real Property Management compliance requirement. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.
FINDING 2024-004 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Federal Agency: U.S. 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): Contract #65873, SLT-3157 Pass-Through Entity: Indiana Department of Natural Resources 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 2023-004. Condition and Context Procurement The County did adopt an applicable federal purchasing policy. The Lake County Indiana Purchasing Manual for Supplies, Services, and Public Works states on page 19 that "Federal funds less than $25,000 will obtain 3 quotes by telephone or fax and obtain board approval. . . ." The Lake County Indiana Purchasing Manual for Supplies, Services, and Public Works also states on page 19 that "Federal funds more than $25,000 but less than $50,000 will invite 3 quotes at an open public meeting." The federal procurement requirement, per the Code of Federal Regulations section 200.320, states that for small purchases, price or rate quotations must be obtained from an adequate number of qualified sources. In 2024, the County had two vendors. One was paid $27,963, and one was paid $12,970 for a total of $40,933 from the COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (SLFRF) under Contract #65873 from the Indiana Department of Natural Resources. However, the County did not obtain price or rate quotes for the applicable vendors under the small purchase threshold as required per its purchasing policy or the federal requirements. Suspension and Debarment Prior to entering into subawards and covered transactions with the 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 and all subawards. The verification is to be done by checking the Excluded Parties List System (EPLS), collecting a certification from that person or entity, or adding a clause or condition to the covered transaction with that person or entity. The County did not have policies or procedures in place related to the suspension and debarment requirements for the SLFRF funds. Three covered transactions totaling $7,530,563 paid from the SLFRF funds were identified. Documentation to show that suspension and debarment was verified prior to entering into contracts with these three vendors could not be provided by the County. The amounts for which suspension and debarment were not verified for Contract #65873 from the Indiana Department of Natural Resources and the SLT-3157 directly from the U.S. Department of the Treasury were $27,963 and $7,502,600, respectively. The lack of internal controls and noncompliance were isolated to the transactions identified above. 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 200.318(i) states: "The non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price." 2 CFR 200.320 states in part: "The non-Federal entity must have and use document procurement procedures, consistent with the standards of this section and §§200.317, 200.318, and 200.319 for any of the following methods of procurement used for the acquisition of property or services required under a Federal award or sub-award. (a) Informal procurement methods. When the value of the procurement for property or services under a Federal award does not exceed the simplified acquisition threshold (SAT), as defined in § 200.1, or a lower threshold established by a non-Federal entity, formal procurement methods are not required. The non-Federal entity may use informal procurement methods to expedite the completion of its transactions and minimize the associated administrative burden and cost. The informal methods used for procurement of property or services at or below the SAT include: . . . (2) Small purchases — (i) Small purchase procedures. The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity. . . ." 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: (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 County's purchasing policy does not provide procedures on how the County will ensure the appropriate number of quotes will be obtained for small purchases or how the County will ensure compliance with the suspension and debarment requirements. Effect Noncompliance with the provisions of federal statutes, regulations, and the terms and conditions of the federal award could result in the repayment or loss of future federal funding to the County. Questioned Costs There were no questioned costs identified. Recommendation Management of the County should develop procedures to ensure the appropriate procurement methods are used for items or services procured that are within the small purchase threshold and to ensure vendors are not suspended or debarred when expending federal funds. Appropriate documentation should be maintained to ensure compliance with procurement and suspension and debarment. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.
FINDING 2024-005 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: U.S. Department of the Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listings Number: 21.027 Federal Award Number and Year (or Other Identifying Number): SLT-3157 Compliance Requirement: Reporting Audit Findings: Material Weakness, Other Matters Repeat Finding This is a repeat finding from the immediately prior audit report. The prior audit finding number was 2023-005. Condition and Context Recipients are required to submit quarterly or annual Project and Expenditure (P&E) reports to the U.S. Department of the Treasury (Treasury). The reporting periods, as well as the respective due dates, are based upon type of recipient and its population as well as the recipient's allocation amount. Information to be reported includes projects funded, expenditures, and contracts for the appropriate reporting period. The County was classified as a county with a population that exceeds 250,000 residents. As such, the County was required to submit quarterly P&E reports in 2024. The amounts submitted for three of the four quarterly P&E reports were not supported by the County's records and contained the following errors: The 2024 Quarter 1 P&E report period and cumulative expenditures were each overstated by $333,424. The 2024 Quarter 2 P&E report period and cumulative expenditures were understated by $842,954 and $509,530, respectively. The 2024 Quarter 3 P&E report period and cumulative expenditures were understated by $239,925 and $749,455, respectively. Additionally, the current period obligations and cumulative obligations amounts reported in all quarterly reports could not be verified as supporting documentation was not provided for audit. The lack of internal controls and noncompliance was a systemic issue 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). . . ." Compliance and Reporting Guidance, State and Local Fiscal Recovery Funds, page 13 states in part: ". . . 13. Reporting. All recipients of federal funds must complete financial, performance, and compliance reporting as required and outlined in Part 2 of this guidance. Expenditures may be reported on a cash or accrual basis, as long as the methodology is disclosed and consistently applied. Reporting must be consistent with the definition of expenditures pursuant to 2 CFR 200.1. Your organization should appropriately maintain accounting records for compiling and reporting accurate, compliant financial data, in accordance with appropriate accounting standards and principles. . . ." 31 CFR 35.4(c) states in part: "Reporting and requests for other information. During the period of performance, recipients shall provide to the Secretary or her delegate, as applicable, periodic reports providing detailed accounting of the uses of funds, . . ." Cause All quarterly P&E reports were prepared and submitted by a consultant without an oversight or review process in place to prevent, or detect and correct, errors prior to submission. Effect Noncompliance with the provisions of federal statutes, regulations, and the terms and conditions of the federal award could result in the repayment or loss of future federal funding to the County. Questioned Costs There were no questioned costs identified. Recommendation We recommended that the County's management establish a proper system of internal controls that would ensure compliance with the Reporting compliance requirement. 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: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - 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): TRSW 2200305, CY 2024 Pass-Through Entity: Indiana Finance Authority 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 federal 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 or services awarded under a nonprocurement transaction (i.e., grant agreement) that are expected to equal or exceed $25,000. Verification is to be done by checking the Excluded Parties List System (EPLS), collecting a certification from that person, or adding a clause or condition to the covered transaction with that person. The County had not properly implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. Covered transactions in the amount of $1,454,478 were made during the audit period to three vendors. A total of $60,732 was paid from the CY 2024 award to one vendor, and a total of $1,393,746 was paid from the TRSW 2200305 award to two vendors. Of the three vendors paid by the County, one vendor contract included a suspension and debarment clause with total payments of $917,636 from the TRSW 2200305 award. For the other two vendors, the County did not check the EPLS nor was a certification collected from the vendors, and a clause did not exist in the agreements with the vendors. One of the vendors was paid a total of $60,732 from the CY 2024 award, and the other vendor was paid $476,110 from the TRSW 2200305 award. Although the County had a policy to include a clause in vendor contracts related to covered transactions, a clause was not included in those two contracts and no other documentation to verify the County's compliance with the suspension and debarment federal requirement was provided for audit. The lack of internal controls and noncompliance were systemic 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). . . ." 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." 2 CFR 200.214 states: "Recipients and subrecipients are subject to the nonprocurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, as well as 2 CFR part 180. The regulations in 2 CFR part 180 restrict making Federal awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from receiving or participating in Federal awards." Cause The system of internal controls established by management of the County was not implemented as designed, and employees lacked sufficient training to carry out suspension and debarment procedures required to certify vendor status. Effect Without the proper implementation of an effectively designed system of internal controls, the system is incapable of effectively preventing, or detecting and correcting, material noncompliance. As a result, the County was not able to provide documentation that the suspension and debarment requirements were followed for two vendors to whom payment was equal to or in excess of $25,000 was paid. Questioned Costs There were no questioned costs identified. Recommendation We recommended that the County's management establish a system of internal controls to ensure compliance and comply with the grant agreements and the Procurement and Suspension and Debarment compliance requirement. Additionally, the County should ensure that all necessary personnel understand the requirements and County policies. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.
U.S. Department of Treasury, COVID- 19 Coronavirus State and Local Fiscal Recovery Funds - 21.027 Criteria or Specific Requirement - Suspension and Debarment and Material Weakness In accordance with 2 CFR 200.214, non-federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. “Covered transactions” include contracts for goods and services awarded under a non-procurement transaction (e.g., grant or cooperative agreement) that are expected to equal or exceed $25,000 or meet certain other criteria as specified in 2 CFR Section 180.220. In accordance with 2 CFR Section 180.300, when a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-federal entity must verify that the entity, as defined in 2 CFR Section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. Per 2 CFR 200.303, the non-Federal entities receiving federal awards (i.e., auditee management) establish and maintain internal control design to reasonably ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition - Suspension and debarment checks were not completed for a vendor prior to entering into a contract. Cause - The City's controls to ensure suspension and debarment checks on vendors receiving federal funds did not operate effectively. Effect - Federal funds could be paid to entities that are suspended or debarred. Questioned Costs - None noted, as the vendor was reviewed and determined to not be suspended or debarred. Context - The City entered into two contracts during the year ended December 31, 2024 that was considered a "covered transaction" and spent approximately $982,000 under this contract. Both contracts selected for testing suspension and debarment and uncovered the City did not check the vendor's suspension and debarment status prior to purchase for the $540,000 contract. The City completed the suspension and debarment check subsequent to purchase and verified the vendor was not suspended or disbarred. Identification as a Repeat Finding, if applicable - None noted. Recommendation - Policies and procedures should be modified to ensure that suspension and debarment checks are performed on vendors prior to making purchases with federal funds. View of Responsible Official and Planned Corrective Actions - Management agrees with the stated finding and has implemented a corrective action plan.
Environmental Protection Agency Direct Program: Congressionally Mandated Projects - 66.202 Award Year: 2023 Criteria or Specific Requirement - Reporting Per 2 CFR 200.303, the non-Federal entities receiving federal awards (i.e., auditee management) should establish and maintain internal control design to reasonably ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal Award. Per the Environmental Protection Agency Congressionally Mandated Project's Programmatic Conditions, non-Federal entities that receive the federal award are required to submit semi-annual performance reports. Condition: During our test work over the Congressionally Mandated Projects grant, we noted the Board of Public Utilities did not timely file one of the required performance reports nor was there a review of the report prior to submission. Cause: The Board of Public Utilities' controls to ensure reports are filed timely and are reviewed prior to filing were not operating effectively. Effect or Potential Effect: Required reports are not being submitted timely. Questioned Costs - None Context: One out of the two semi-annual reports selected for testing was submitted on May 13, 2024, after the Environmental Protection Agency's due date of April 30, 2024. It was also noted through discussions with the Board of Public Utilties, no review of the report was completed prior to submission. The sample was not intended to be, and was not, a statistically valid sample. Identification of Prior Year Finding: N/A Recommendation: We recommend that the Board of Public Utilities implement a process that includes tracking the timely submission of reports and documenting review of the report prior to submission. Views of Responsible Official and Planned Corrective Action: Management agrees with finding. See corrective action plan.
Environmental Protection Agency Direct Program: Congressionally Mandated Projects - 66.202 Award Year: 2023 Criteria or Specific Requirement - Davis-Bacon Act Per 2 CFR 200.303, the non-Federal entities receiving federal awards (i.e., auditee management) should establish and maintain internal control design to reasonably ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal Award. Per the Environmental Protection Agency Congressionally Mandated Project's Programmatic Conditions, non-Federal entities that receive the federal award are required to maintain adequate records to demonstrate compliance with compensation requirements. Condition: During our test work over the Congressionally Mandated Projects grant, we noted the Board of Public Utilities did not obtain Statements of Compliance/Certified Payrolls from the applicable vendors in timely manner. Cause: The Board of Public Utilities' controls to ensure that the Statements of Compliance/Certified Payrolls are submitted timely were not operating effectively. Effect or Potential Effect: The Board of Public Utilities was unable to demonstrate compliance with Davis-Bacon wage rate requirements. Questioned Costs - None noted. Context: For all weeks selected for testing, the subcontractor did not submit the required Statements of Compliance within a timely manner. The sample was not intended to be, and was not, a statistically valid sample. Identification of Prior Year Finding: N/A Recommendation: We recommend that the Board of Public Utilities implement a process that includes tracking the timely submission of Statements of Compliance and documenting review of the Statements once received. Views of Responsible Official and Planned Corrective Action: Management agrees with finding. See corrective action plan.
FINDING 2024-002 Subject: Airport Improvement Program - Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Transportation Federal Programs: Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs Assistance Listings Number: 20.106 Award Numbers or Years (or Other Identifying Numbers): 3-18-0025-018-2022, 3-18-0025-019-2023, 3-18-0025-020-2024, 3-18-0025-021-2024 Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Audit Finding: Material Weakness Condition and Context Construction contracts in excess of $2,000 financed by federal assistance funds must pay wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (DOL) to their laborers and mechanics. Nonfederal entities are to include in their construction contracts subject to the Wage Rate Requirements a provision that the contractor or subcontractor comply with these requirements and the DOL regulations. This would include a requirement to submit a copy of the payroll and statement of compliance to the entity for each week in which contract work was performed. The certified payrolls were completed and submitted weekly by the contractor as required; however, there were no internal controls in place at the Town that would be effective in preventing, or detecting and correcting, noncompliance. There was no evidence to ensure all applicable payrolls were received by the Town and that, once received, certified payrolls were reviewed by the Town to ensure that the wage rate compliance requirement was met. 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). . . ." Cause The Town did not design or implement a system of internal controls over the Special Tests and Provisions - Wage Rate Requirements compliance requirement. Effect Without the proper implementation of an effectively designed system of internal controls, errors could occur and remain undetected. As such, the Town cannot ensure that the certified payrolls have been properly submitted and reviewed. INDIANA STATE BOARD OF ACCOUNTS 15 TOWN OF KENTLAND SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Questioned Costs There were no questioned costs identified. Recommendation We recommended that management of the Town design and implement a proper system of internal controls, including policies and procedures, to ensure that the Town is provided complete and accurate certified payrolls for the wage rate requirement. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report. INDIANA STATE BOARD OF ACCOUNTS 16
2024-007 Eligibility – MAXIS Prior Year Finding Number: N/A Year of Finding Origination: 2024 Type of Finding: Internal Control Over Compliance and Compliance Severity of Deficiency: Material Weakness and Modified Opinion Federal Agency: U.S. Department of Health and Human Services Program: 93.778 Grants to States for Medicaid Award Number and Year: 2405MN5ADM; 2024 Pass-Through Agency: Minnesota Department of Human Services Criteria: Title 2 U.S. Code of Federal Regulations § 200.303 states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Title 42 U.S. Code of Federal Regulations §§ 435.911 and 435.945 require the state Medicaid agency to determine and verify eligibility of enrollees in Medicaid. The Minnesota Department of Human Services provides the Minnesota Health Care Programs Eligibility Policy Manual. The manual contains the Minnesota Department of Human Services eligibility policies for the Minnesota Health Care Programs, including the eligibility requirements of Medical Assistance. Specific eligibility requirements are included for participants’ citizenship verification and asset verification. Minnesota Statutes, section 256B.05, requires county agencies to administer Medical Assistance. Condition: The Minnesota Department of Human Services maintains the computer system, MAXIS, which is used by Wilkin County to support the eligibility determination process. In the participant files reviewed for eligibility, not all documentation to support participant eligibility was available, updated, or input correctly. The following exceptions were noted in the sample of 40 participant files tested: • three participants’ citizenship information did not have the birth certificate in the file; and • one participant’s asset information did not match the documentation in the file, and three participant files did not have supporting asset documentation in the file. Questioned Costs: Not applicable. The County administers the program, but the State of Minnesota pays benefits to participants in this program. Context: The State of Minnesota and the County split the eligibility determination process. Pursuant to Minnesota statutes, Wilkin County performs the “intake function” needed for this program, while the State maintains the MAXIS systems, which supports the eligibility determination process. Participants receive benefit payments from the State. The population consisted of 336 active MAXIS participant cases enrolled in Grants to States for Medicaid in 2024; the sample size was 40 participant files. The sample size was based on the guidance from Chapter 11 of the AICPA Audit Guide, Government Auditing Standards and Single Audits. Effect: The improper input or updating of information into MAXIS and the lack of verification or follow-up of eligibility-determining factors increase the risk that program participants will receive benefits when they are not eligible. Cause: Program personnel entering case file information into MAXIS did not ensure all required information was input or updated correctly, supported, and retained. Recommendation: We recommend Wilkin County implement additional procedures to provide reasonable assurance that all documentation needed to support eligibility determinations exists, the program personnel properly input or update the documentation in MAXIS, and the program personnel follow up on issues in a timely manner. In addition, Wilkin County should consider providing further training to program personnel. View of Responsible Official: Concur
2024-008 Suspension and Debarment Prior Year Finding Number: 2023-002 Year of Finding Origination: 2023 Type of Finding: Internal Control Over Compliance and Compliance Severity of Deficiency: Significant Deficiency and Other Matter Federal Agency: U.S. Department of the Treasury Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Award Number and Year: SLFRP2411; 2021 Pass-Through Agency: N/A – Direct Criteria: Title 2 U.S. Code of Federal Regulations § 200.303 states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Federal requirements prohibit non-federal entities from contracting with or making subawards under covered transactions to parties that are suspended or debarred. Title 2 U.S. Code of Federal Regulations § 180.300 describes a required verification process. Prior to entering into the transaction, one of the following must be performed: (1) checking SAM.gov exclusions, (2) collecting a certification, or (3) adding a clause or condition to the covered transaction. Condition: For the two covered transactions tested, the County did not maintain documentation of verification that the vendors were not suspended or debarred prior to entering into the covered transactions. Questioned Costs: $187,679; known questioned costs were determined based on payments to the two vendors tested. Context: During the year, the County entered into three covered transactions using COVID-19 – Coronavirus State and Local Fiscal Recovery Funds. The covered transactions totaled $222,953. The sample size was based on the guidance from Chapter 11 of the AICPA Audit Guide, Government Auditing Standards and Single Audits. Effect: Failure to verify vendors are not suspended, debarred, or otherwise excluded prior to entering into a covered transaction may result in the County entering into a transaction with a vendor that is not authorized to provide goods and services under the grant. Cause: The County indicated significant staff turnover in key positions. The previous staff were not available to locate the documentation. Recommendation: We recommend the County maintain documentation to demonstrate that vendors were not debarred, suspended, or otherwise excluded from conducting business with the County; the County should complete this documentation prior to entering into a covered transaction. View of Responsible Official: Concur
2024-006 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Prior Year Finding Number: N/A Year of Finding Origination: 2024 Type of Finding: Internal Control Over Compliance and Compliance Severity of Deficiency: Material Weakness and Modified Opinion Federal Agency: U.S. Department of Health and Human Services Program: 93.778 Grants to States for Medicaid Award Number and Year: 2405MN5ADM; 2024 Pass-Through Agency: Minnesota Department of Human Services Criteria: Title 2 U.S. Code of Federal Regulations § 200.303 states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Title 2 U.S. Code of Federal Regulations §§ 200.403(a) and 200.403(g) require costs to be necessary and reasonable, and be adequately documented. For federal awards received from the Minnesota Department of Human Services (DHS), internal controls should be established and maintained to provide assurance that program reports submitted to DHS are completed and documented in accordance with DHS reporting instructions. As part of Wilkin County’s reporting requirements, the Public Health Department submits the Local Collaborative Time Study (LCTS) Public Health Cost Schedule DHS-3220.3 on a quarterly basis. Condition: The County did not maintain adequate support for the reported payroll amounts on LCTS Public Health Cost Schedule DHS-3220.3 reports tested. The reports also had no documentation of review. Questioned Costs: $329,183; known questioned costs were determined based on the payroll costs from each of the four LCTS Public Health Cost Schedule DHS-3220.3 reports. Context: Minnesota DHS relies on accurate submission of program costs to ensure that resulting grant funds paid to Wilkin County are for applicable federal program activities/costs. Total expenditures reported on the Schedule of Expenditures of Federal Awards are $416,193. Amounts reported on the DHS-2550, DHS-2556, and LCTS Public Health Cost Schedule DHS-3220.3 reports were $759,694, $1,879,054, and $379,254, respectively. The State of Minnesota determines the reimbursement of reported expenditures. The reporting population consisted of four quarterly DHS-2550, DHS-2556, and LCTS Public Health Cost Schedule DHS-3220.3 reports; and originally a sample of two of each report type was selected for report testing. Additionally, a sample of 40 expenditures were selected for testing, which included five LCTS Public Health Cost Schedule DHS-3220.3 expenditures for testing. Payroll reported expenditure testing relating to the LCTS Public Health Cost Schedule DHS-3220.3 was expanded to cover payroll expenditures of all four quarters.The sample size was based on the guidance from Chapter 11 of the AICPA Audit Guide, Government Auditing Standards and Single Audits, and subsequently expanded. Effect: Errors in the identification and reporting of costs on the quarterly reports can impair DHS’ ability to provide required oversight over federal programs and result in the County receiving either more or less federal funds than justified based on the actual underlying activity. Cause: The employee who prepared the reports and the supporting documentation left the County in 2025. The supporting documentation could not be located. Recommendation: We recommend the County implement controls to ensure activities allowed and allowable costs are appropriately identified and accurately reported to DHS in accordance with federal program guidance and DHS instructions, including that reports are reviewed by someone other than the preparer. We also recommend the County correct and resubmit reports submitted with unallowable activities or costs, costs allocated incorrectly, or activity reporting incorrectly. View of Responsible Official: Concur
2024-009 Reporting Prior Year Finding Number: N/A Year of Finding Origination: 2024 Type of Finding: Internal Control Over Compliance and Compliance Severity of Deficiency: Material Weakness and Modified Opinion Federal Agency: U.S. Department of the Treasury Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Award Number and Year: SLFRP2411; 2021 Pass-Through Agency: N/A – Direct Criteria: Title 2 U.S. Code of Federal Regulations § 200.303 states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The U.S. Department of the Treasury requires recipients of funds to submit Project and Expenditure Reports that include, by project, current period obligations, cumulative obligations, current period expenditures, and cumulative expenditures. The frequency of reporting is dependent on the size of the entity and amount of funding received. Condition: The County understated current period expenditures reported, and cumulative expenditures reported on the annual Project and Expenditure Report submitted to the U.S. Department of the Treasury by $182,285. Also, the County did not submit the annual Project and Expenditure Report by the federal deadline of April 30, 2024. Questioned Costs: None. Context: The County opted to spend the COVID-19 – Coronavirus State and Local Fiscal Recovery Funds award under the Revenue Replacement category, which allows spending on broader types of government services. The annual Project and Expenditure Report required to be submitted to the U.S. Department of the Treasury by April 30 of each year for the reporting period ending March 31 was submitted August 14, 2024. Effect: The County is not in compliance with federal reporting requirements. Cause: The County indicated difficulty tracking project expenditures due to staff turnover. Recommendation: We recommend the County review the U.S. Department of the Treasury’s guidance and form instructions to ensure accurate reporting of COVID-19 – Coronavirus State and Local Fiscal Recovery Funds activity. We also recommend the County submit future Project and Expenditure Reports by the federal deadline. View of Responsible Official: Concur
Condition: During our testing of allowable activities/cost and period of performance it was noted the Organization did not perform or document required approval/review over expenditures. Criteria: Per § 200.303 of the Code of Federal Regulations, recipients must establish, document, and maintain internal controls over Federal awards that provides reasonable assurance that the recipient is managing the Federal Award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Cause: The Organization lacked formal policies and procedures to ensure documentation and performance of approval/review over expenditures and applications. The responsibility for oversight along with monitoring activities was not documented. Effect: Failure to establish, document, and maintain internal controls increases the risk that federal funds may not be used in accordance with applicable laws and regulations, potentially resulting in noncompliance with program requirements. Context: This condition was identified in all sampled populations of allowable activities/cost and period of performance. This finding is a repeat finding of the immediate prior audit. Reference number includes 2023-004. Recommendation: We recommend the Organization develop and implement formal documented review/approval and monitoring procedures which include the written or electronic signature of authorized individuals on invoices. Management has noted that they have implemented procedures beginning in 2025 to address this finding. Views of Responsible Officials: Management agrees with the finding.
Finding 2024-001 Audit Delays Federal Agencies: U.S. Department of State and U.S. Agency for International Development Federal Programs: International Programs to Support Democracy, Human Rights and Labor and Foreign Assistance for Programs Overseas Assistance Listing Numbers: 19.345 and 98.001 Pass-through Entity: None Award Identification Number and Year: S-LMAQM-20-GR-2099, S-LMAQM-20-GR-2100, SAQMIP- 22-GR-0005, S-AQMIP-23-GR-0343, 720-523-18-CA-00006, 720-486-23-LA-00001 Criteria or Specific Requirement: As noted in 2 CFR §200.303 "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)". As noted in 2 CFR §200.512 the audit report should be submitted nine months after the end of the audit period. Condition: There were delays in performing the audit, resulting in a late filing of the Uniform Guidance audit. In addition, we noted that certain accounts had not been reconciled throughout the year, but instead as part of audit preparation only. We noted that reconciliation of the indirect rate had also been delayed due to late receipt of a final rate and that further analysis is pending to determine any adjustments that may be required from the final rate determination. Cause: The above conditions arose due to numerous factors, including transition and turnover within the accounting department. Effect or Potential Effect: Timely year-end closure is important to avoid increased potential for fraud, misstatements, and failures to adhere to donor and other regulations. Effective filing of documents decreases the potential for non-compliance with donor requirements, questioned costs or findings. Questioned Costs: None Context: ICFJ has been impacted by funding changes as well as transition in staff within the acconting department. Identification as a Repeat Finding, if Applicable: Not applicable Recommendation: We recommend that ICFJ ensure that a monthly close process is followed to ensure timely and accurate financial reporting, transparent documentation of review and approval of transactions, and compliance with applicable donor requirements. Financial and compliance documents should be filed to permit prompt retrieval.
Finding 2024-004 Cash Management Federal Agencies: U.S. Department of State and U.S. Agency for International Development Federal Programs: International Programs to Support Democracy, Human Rights and Labor and Foreign Assistance for Programs Overseas Assistance Listing Numbers: 19.345 and 98.001 Pass-through Entity: None Award Identification Number and Year: S-LMAQM-20-GR-2099, S-LMAQM-20-GR-2100, SAQMIP- 22-GR-0005, S-AQMIP-23-GR-0343, 720-523-18-CA-00006, 720-486-23-LA-00001 Criteria or Specific Requirement: Under 2 CFR 200.303, organizations that receive Federal funding are required to “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: Evidence of review/approval for certain drawdown requests could not be provided. The supporting documentation for certain requests (i.e. the schedule documenting the calculation for the amount requested) was also not available. While management asserts that a review and approval of drawdown requests occurred, there is no audit trail that shows the evidence of the control occurring. Cause: ICFJ experienced transition during the fiscal year and certain documents were unable to be located during the audit process. Effect or Potential Effect: Appropriate procedures and documentation for drawdown requests is important to ensure compliance with cash management compliance requirements. Questioned Costs: None Context: Our audit procedures consisted of testwork performed over cash receipts and drawdown requests from the Federal Government. We consider our sample to be representative of the population. The condition appears to be systemic in nature. Identification as a Repeat Finding, if Applicable: This is a repeat finding (2023-004) Recommendation: We recommend that management of ICFJ implement procedures and control processes to incorporate and document an independent review and approval, evidenced by a signature/initialing and date of the review and approval taking place prior to submission to the funder. Each request should be filed with the documentation supporting the calculation of the request.
Criteria: In accordance with 2 CFR §200.303, the auditee must establish and maintain effective internal control over federal awards to provide reasonable assurance that expenditures are properly recorded and reported in compliance with applicable laws, regulations, and the terms and conditions of the award. Condition: During testing of allowability, we identified instances in which expenditures were coded to incorrect accounts within the general ledger. Cause: Based on inquiry with management, the errors occurred due to the implementation of new accounting software during the year under audit, which resulted in inconsistencies in account mapping and user understanding of the updated chart of accounts. Effect: Improper coding of expenditures increases the risk that costs may be misclassified or reported incorrectly on financial reports and federal schedules, including the SEFA. This could lead to noncompliance with federal reporting requirements and reduce the reliability of financial information used for decision-making. Recommendation: We recommend that management strengthen internal controls over financial reporting by (1) providing additional training to personnel on the updated accounting system and chart of accounts, (2) implementing a review process to verify proper coding of expenditures, particularly following system changes, and (3) performing periodic reconciliations and monitoring procedures to detect and correct misclassifications in a timely manner. Foundation Response: Management agrees with the finding.
2024-003 Improve Internal Controls Over Reporting Federal Program(s) Information Federal Agency: U.S. Department of the Treasury Award Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award Year: 2021 Compliance Requirement: Reporting Type of Finding Compliance Internal Control over Compliance – Material Weakness Criteria or Specific Requirement 2 CFR 200.303 requires the County to establish and maintain effective internal controls over federal awards to ensure compliance with federal statutes, regulations, and the terms and conditions of the award. Per U.S. Department of the Treasury’s Coronavirus State and Local Fiscal Recovery Funds: Compliance and Reporting Guidance, recipients are required to accurately report project-level information, including the breakdown of expenditures by individual project, and to avoid duplicative or misclassified reporting of expenditures across reporting periods. Condition and Context During our audit, it was determined that the County did not submit its quarterly performance and evaluation report to Treasury within the required timeline for the quarter 2 2024 report (April-June). Further, there is no documented review of the project and expenditure reports by an individual that is not involved with preparing the reports. Additionally, key line items, specifically current period expenditures and total cumulative expenditures, included on the project and expenditure reports for quarters 2 and 4 of 2024 (April–June and October–December) did not agree to the general ledger, as required by the terms of the grant agreement. Cause The County’s internal controls over federal award reporting did not ensure expenditures were accurately reported. Effect or Potential Effect Inaccurate reporting of project-level and current period expenditure information increases the risk of noncompliance with federal reporting requirements and impairs the transparency and oversight expected by the Treasury. No questioned costs are reported as the requirement is procedural in nature and costs reported were ultimately deemed allowable. Recommendation The County should address the weakness in internal controls noted above by requiring two individuals to be involved in preparing and reviewing reports submitted to federal agencies to ensure the reports are complete and accurate. Views of Responsible Official Management’s corrective action plan is included at the end of this report after the Schedule of Prior Year Findings.
Criteria: 2 CFR §200.510(b) requires the auditee to prepare a complete and accurate Schedule of Expenditures of Federal Awards (SEFA) that includes the total federal awards expended for the period, identified by federal agency, pass-through entity (as applicable), assistance listing number (ALN), and other required elements. 2 CFR §200.303 requires the auditee to establish and maintain effective internal controls over federal awards to provide reasonable assurance of compliance with statutes, regulations, and the terms and conditions of federal awards. Under GAGAS and Uniform Guidance, internal controls should ensure that federal expenditures are properly accumulated, reconciled, reviewed, and reported in the SEFA. Condition: Our audit of the SEFA for the year ended December 31, 2024, federal expenditures totaling approximately $1,586,906 were omitted from the SEFA initially prepared by management. The omitted amount represented approximately 27% of total federal expenditures for the year and included activity under the Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027. The SEFA was subsequently adjusted to include these expenditures. Cause: The entity’s SEFA preparation process did not include sufficient procedures to ensure completeness. Specifically: • The SEFA was prepared using incomplete grant tracking reports that were not reconciled to the general ledger and grant agreements. • There was no formal secondary review by personnel independent of the preparer. • Procedures were not designed to ensure all pass-through federal awards were identified and included. Effect: The omission resulted in initially materially misstated SEFA and noncompliance with SEFA reporting requirements under 2 CFR §200.510(b). The deficiency required significant auditor proposed adjustments to correct the SEFA. This control deficiency constitutes a material weakness because it indicates that the entity’s internal controls over SEFA preparation were not effective to prevent or detect a material misstatement on a timely basis. In addition, the incomplete SEFA could lead to inaccurate reporting to oversight agencies and may affect risk assessments for program compliance. Recommendation: 1. Comprehensive Reconciliation: Reconcile federal grant activity (drawdowns, expenditures, indirect costs) to the general ledger, grant agreements, and agency/portal records. 2. Program Inventory & Certifications: Maintain a centralized inventory of all federal awards (by ALN, pass-through, award number) with program manager certifications of completeness at year-end. 3. Formal Review Workflow: Establish a documented secondary review by finance leadership independent of the preparer, with checklists covering ALNs, pass-throughs, subrecipient disclosures, notes to SEFA, and indirect cost treatment. 4. Subrecipient & Pass-Through Controls: Implement procedures to capture and verify all subrecipient amounts, pass-through activity, and required subrecipient disclosures on the SEFA. 5. Close Calendar & Training: Adopt an annual SEFA close calendar with milestones and provide training on Uniform Guidance reporting requirements to staff involved in SEFA compilation and review. Management Response: Management agrees with the finding. The omission resulted from incomplete reconciliation of grant activity and insufficient review controls.
Assistance Listing Number, Federal Agency, and Program Name: Assistance Listing Number 17.235, Senior Community Service Employment Program Federal Award Identification Number and Year: 2022-1 Finding Type – Significant deficiency in internal control over compliance Repeat Finding - No Criteria – Per 2 CFR § 200.303, 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). Condition – During our testing for Reporting compliance, it was noted the client failed to submit the monthly expenditure reports for the period ended June 30, 2024 within the required time frame. Context – The required reports were not submitted by the due date. Identification of How Questioned Costs Were Computed – N/A Questioned Costs – None Cause – Management noted that the accounting staff were not completing necessary accounting tasks in a timely manner and, therefore required reports were not submitted on time. Effect – The reports were submitted late. Recommendation – We recommend management increase awareness of federal program compliance requirements and monitor compliance with the requirements on regular basis. In addition, we recommend that management review its procedures and controls in place to ensure that reports are completed and submitted by the required due dates. View of Responsible Officials and Corrective Action Plan – Management agrees with finding. See corrective action plan.
Assistance Listing Number, Federal Agency, and Program Name: Assistance Listing Number 21.027, Coronavirus State and Local Fiscal Recovery Funds Federal Award Identification Number and Year: 2022-0001 & E20250728-002 & E20250157-001 Finding Type – Significant deficiency in internal control over compliance Repeat Finding - No Criteria – Per 2 CFR § 200.303, 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). Condition – During our testing for Reporting compliance, it was noted the client failed to submit the monthly expenditure reports for the period ended January 31, 2024, February 29, 2024, April 30, 2024, June 30, 2024, July 31, 2024, September 30, 2024, November 30, 2024, and December 31, 2024 within the required time frame. Context – The required report was not submitted by the due date. Identification of How Questioned Costs Were Computed – N/A Questioned Costs – None Cause – Management noted that the accounting staff were not completing necessary accounting tasks in a timely manner and, therefore required reports were not submitted on time. Effect – The report was submitted late. Recommendation – We recommend management increase awareness of federal program compliance requirements and monitor compliance with the requirements on regular basis. In addition, we recommend that management review its procedures and controls in place to ensure that reports are completed and submitted by the required due dates. View of Responsible Officials and Corrective Action Plan – Management agrees with finding. See corrective action plan.
Subrecipient Monitoring Federal Department – U.S. Department of Justice Pass-through Illinois Criminal Justice Information Authority Federal Award Identification Number and Year: 15JOVW-21-GG-00543-STOP and 2021 15JOVW-22-GG-00422-STOP and 2022 Violence Against Women Formula Grants, Federal Assistance Listing #16.588 County Department – State’s Attorney Office Finding 2024 – 002 CRITERIA 2 CFR Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart D—Post Federal Award Requirements Standards for Financial and Program Management, Section 200.303 Internal controls states, “the recipient and subrecipient must: (a) Establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient or subrecipient is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” Section 200.332. Requirements for pass-through entities, requires that “A pass-through entity must: (c) Evaluate each subrecipient's fraud risk and risk of noncompliance with a subaward to determine the appropriate subrecipient monitoring described in paragraph (f) of this section. When evaluating a subrecipient's risk, a pass-through entity should consider the following: (1) The subrecipient's prior experience with the same or similar subawards; (2) The results of previous audits. This includes considering whether or not the subrecipient receives a Single Audit in accordance with subpart F and the extent to which the same or similar subawards have been audited as a major program; (3) Whether the subrecipient has new personnel or new or substantially changed systems; and (4) The extent and results of any Federal agency monitoring (for example, if the subrecipient also receives Federal awards directly from the Federal agency)... (e) Monitor the activities of a subrecipient as necessary to ensure that the subrecipient complies with Federal statutes, regulations, and the terms and conditions of the subaward. The pass-through entity is responsible for monitoring the overall performance of a subrecipient to ensure that the goals and objectives of the subaward are achieved. In monitoring a subrecipient, a pass-through entity must:(1) Review financial and performance reports. (2) Ensure that the subrecipient takes corrective action on all significant developments that negatively affect the subaward. Significant developments include Single Audit findings related to the subaward, other audit findings, site visits, and written notifications from a subrecipient of adverse conditions which will impact their ability to meet the milestones or the objectives of a subaward. When significant developments negatively impact the subaward, a subrecipient must provide the pass-through entity with information on their plan for corrective action and any assistance needed to resolve the situation. (3) Issue a management decision for audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by § 200.521.(4)Resolve audit findings specifically related to the subaward…. (g)Verify that a subrecipient is audited as required by subpart F of this part. (h) Consider whether the results of a subrecipient's audit, site visits, or other monitoring necessitate adjustments to the pass-through entity's records. (i) Consider taking enforcement action against noncompliant subrecipients as described in § 200.339 and in program regulations. CONDITION During the current audit period, the Cook County State’s Attorney Office (SAO) did not adequately comply with its subrecipient monitoring requirements as required by Federal regulations. CAUSE Based on discussions with management, the cause of this finding was an inadequate understanding of sub-recipient monitoring policies and best practices. While the Department believed at the time that they were in compliance with the applicable monitoring requirements, they now recognize that their efforts did not fully meet the necessary standards. EFFECT Failure to adequately perform and document the risk assessments on its subrecipient(s) could result in the inadequate monitoring of the activities and performance of a subrecipient. Also, this could result in Federal awards being used by the subrecipient for unauthorized purposes. QUESTIONED COSTS None. CONTEXT During our review of two (2) subrecipients (of a population of 4 subrecipients), we noted the following: For both subrecipients, we noted documentation was not maintained to support SAO’s evaluation of the subrecipients’ risk of noncompliance and the frequency of monitoring to be conducted by SAO based on the assessed risk. We also noted for both subrecipients, no documentation was provided to verify whether the subrecipients were required to have a Single Audit conducted, including SAO’s review of the report, and if applicable, issuance of a management decision on audit findings noted as required by 2 CFR 200.332e(3). The SAO utilized a “Subrecipient Monitoring Checklist” (Checklist) to conduct and document its monitoring of subrecipients. Based on review, we noted the Checklist does not include evidence of who completed the monitoring, the date the actual monitoring was performed nor the subrecipient personnel with whom the monitoring results were discussed during the site visit. Also, the Checklist appears to be inaccurately completed. Specifically, we noted the Checklist noted that the results include expected corrective actions and dates for resolution. However, there was no finding or issues noted in the formal letter submitted to the subrecipient(s) after the site visit(s). IDENTIFICATION OF REPEATED FINDINGS None. RECOMMENDATION We recommend SAO implement procedures to ensure adequate documentation is maintained to support the evaluation of each subrecipient’s risk of noncompliance and review of the Single audit report, as required by Federal regulations. Also, we suggest that the Checklist be accurately prepared and updated to include evidence of who completed the monitoring, the date the actual monitoring was performed, and the subrecipient personnel with whom the monitoring results were discussed during the site visit. VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTIONS The County agrees with the finding and recommendation. The County’s corrective action plan is on pages 38-39.
Assistance Listing, Federal Agency, and Program Name COVID 19 21.027, U.S. Department of Treasury, Coronavirus State and Local Fiscal Recovery Fund Federal Award Identification Number and Year N/A Pass through Entity Michigan Department of Health and Human Services Finding Type Material weakness and material noncompliance with laws and regulations Repeat Finding No Criteria The City must establish and maintain effective internal controls to ensure compliance with federal requirements including period of performance as outlined in 2 CFR 200.303. Condition The City lacked adequate controls to verify that expenditures charged to the grant were incurred within the proper period of performance. Transactions were processed without sufficient review or procedures around the period of performance, resulting in expenditures being charged from outside the allowable timeframe. 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 the year, the City requested reimbursement for $151,621 of expenditures that were not within the period of performance. Cause and Effect The City's control for identifying whether expenditures charged to the grant was not effective as it relied on the date of the vendor's invoice and not the period in which the services were performed. As a result, reports and reimbursement requests improperly included $64,109 of expenditures incurred prior to the period of performance. The City identified the error after year end and appropriately excluded the expenditures from the final SEFA. Later, it was discovered that an additional $87,512 was improperly included on the SEFA. The City removed the additional expenditures discovered from the SEFA as well, thus creating no questioned costs. Recommendation Internal controls should be strengthened to ensure expenditures are being properly reviewed for period of performance before submitting for reimbursement. Views of Responsible Officials and Corrective Action Plan The CIty concurs with this finding and has already implemented controls to look specifically at service period of expenditures when reviewing invoices and submitting reports and reimbursement requests.
2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale (repeated, prior two years 2023-101 and 2022-101) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), COVID-19 H8L50549 (2023), and COVID-19 H8G48569 (2022). Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. This has been a systemic issue as a repeat finding in the prior years. The sample was not statistically valid. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Thirteen of the sixty encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Health centers must prepare and apply a sliding fee discount schedule, so that the amounts owed for health center services by eligible patients are adjusted based on the patient's ability to pay (42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in 13 of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained in what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customary billing rates for all services until all documentation is received, or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025.
2024-104 Lack of Controls Related to Filing Reports (repeated, prior years 2023-104) (initially reported 2023) Assistance Listing Number: 93.224, 93.527 and 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program and Rural Telemedicine Grants Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), C1650381 (2023), COVID-19 H8L50549 (2023), COVID-19 H8G48569 (2022).GA142923 (2021) G2846293 (2022) and G3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $0 Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. In four of the reports selected for testing under ALN 93.224 and 93.527 two reports did not have documentation of approval by the CEO prior to submission. In three of the reports selected for testing under ALN 93.211 two reports did not have documentation of approval by the CEO prior to submission. This is a systemic issue that has been a finding in the previous year. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Cause: The Organization did not have a process in place for review of the data being reported on the HRSA website for the funds being expensed under the federal award programs. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be kept that clearly documents who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025.
2024-105 Lack of Payroll Review and Approval (repeated, prior year 2023-105) (initially reported 2023) Assistance Listing Number: 93.224, 93.527 and 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs, Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll, and the finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors’ approval of time recorded by employees. This is a systemic issue and has been a finding in the previous year. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards The requirement is for the Organization to have a process in place to correctly calculate, record, and pay payroll related expenses in accordance with grant and program requirements. Cause: The Organization does not have an effective process to review, approve, and document the supervisor’s approvals prior to making the payments. Effect: This situation provides an opportunity for errors and unauthorized transactions to occur and not be detected in a timely manner resulting in payroll expenses to be charged incorrectly to the federal awards. Recommendation: In April 2024, the Organization began using a third-party service provider to process payroll resulting in new control processes over the approval of time sheets by supervisors. We recommend that the Organization implement internal control procedures under the new payroll processes to ensure that documentation of supervisor approval of time sheets and subsequent payments is kept on file. Views of Responsible Officials and Planned Corrective Actions: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employees’ time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manager providing the final approval within ADP once all items are confirmed. This entire process is fully documented, with approvals recorded within ADP by employees and supervisors and the shared file drive where HR and Finance initial off on the reviewed payroll items, ensuring a traceable record of the entire payroll approval process.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale (repeated, prior two years 2023-101 and 2022-101) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), COVID-19 H8L50549 (2023), and COVID-19 H8G48569 (2022). Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. This has been a systemic issue as a repeat finding in the prior years. The sample was not statistically valid. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Thirteen of the sixty encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Health centers must prepare and apply a sliding fee discount schedule, so that the amounts owed for health center services by eligible patients are adjusted based on the patient's ability to pay (42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in 13 of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained in what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customary billing rates for all services until all documentation is received, or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025.
2024-104 Lack of Controls Related to Filing Reports (repeated, prior years 2023-104) (initially reported 2023) Assistance Listing Number: 93.224, 93.527 and 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program and Rural Telemedicine Grants Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), C1650381 (2023), COVID-19 H8L50549 (2023), COVID-19 H8G48569 (2022).GA142923 (2021) G2846293 (2022) and G3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $0 Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. In four of the reports selected for testing under ALN 93.224 and 93.527 two reports did not have documentation of approval by the CEO prior to submission. In three of the reports selected for testing under ALN 93.211 two reports did not have documentation of approval by the CEO prior to submission. This is a systemic issue that has been a finding in the previous year. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Cause: The Organization did not have a process in place for review of the data being reported on the HRSA website for the funds being expensed under the federal award programs. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be kept that clearly documents who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025.
2024-105 Lack of Payroll Review and Approval (repeated, prior year 2023-105) (initially reported 2023) Assistance Listing Number: 93.224, 93.527 and 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs, Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll, and the finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors’ approval of time recorded by employees. This is a systemic issue and has been a finding in the previous year. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards The requirement is for the Organization to have a process in place to correctly calculate, record, and pay payroll related expenses in accordance with grant and program requirements. Cause: The Organization does not have an effective process to review, approve, and document the supervisor’s approvals prior to making the payments. Effect: This situation provides an opportunity for errors and unauthorized transactions to occur and not be detected in a timely manner resulting in payroll expenses to be charged incorrectly to the federal awards. Recommendation: In April 2024, the Organization began using a third-party service provider to process payroll resulting in new control processes over the approval of time sheets by supervisors. We recommend that the Organization implement internal control procedures under the new payroll processes to ensure that documentation of supervisor approval of time sheets and subsequent payments is kept on file. Views of Responsible Officials and Planned Corrective Actions: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employees’ time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manager providing the final approval within ADP once all items are confirmed. This entire process is fully documented, with approvals recorded within ADP by employees and supervisors and the shared file drive where HR and Finance initial off on the reviewed payroll items, ensuring a traceable record of the entire payroll approval process.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale (repeated, prior two years 2023-101 and 2022-101) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), COVID-19 H8L50549 (2023), and COVID-19 H8G48569 (2022). Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. This has been a systemic issue as a repeat finding in the prior years. The sample was not statistically valid. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Thirteen of the sixty encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Health centers must prepare and apply a sliding fee discount schedule, so that the amounts owed for health center services by eligible patients are adjusted based on the patient's ability to pay (42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in 13 of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained in what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customary billing rates for all services until all documentation is received, or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025.
2024-104 Lack of Controls Related to Filing Reports (repeated, prior years 2023-104) (initially reported 2023) Assistance Listing Number: 93.224, 93.527 and 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program and Rural Telemedicine Grants Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), C1650381 (2023), COVID-19 H8L50549 (2023), COVID-19 H8G48569 (2022).GA142923 (2021) G2846293 (2022) and G3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $0 Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. In four of the reports selected for testing under ALN 93.224 and 93.527 two reports did not have documentation of approval by the CEO prior to submission. In three of the reports selected for testing under ALN 93.211 two reports did not have documentation of approval by the CEO prior to submission. This is a systemic issue that has been a finding in the previous year. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Cause: The Organization did not have a process in place for review of the data being reported on the HRSA website for the funds being expensed under the federal award programs. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be kept that clearly documents who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025.
2024-105 Lack of Payroll Review and Approval (repeated, prior year 2023-105) (initially reported 2023) Assistance Listing Number: 93.224, 93.527 and 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs, Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll, and the finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors’ approval of time recorded by employees. This is a systemic issue and has been a finding in the previous year. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards The requirement is for the Organization to have a process in place to correctly calculate, record, and pay payroll related expenses in accordance with grant and program requirements. Cause: The Organization does not have an effective process to review, approve, and document the supervisor’s approvals prior to making the payments. Effect: This situation provides an opportunity for errors and unauthorized transactions to occur and not be detected in a timely manner resulting in payroll expenses to be charged incorrectly to the federal awards. Recommendation: In April 2024, the Organization began using a third-party service provider to process payroll resulting in new control processes over the approval of time sheets by supervisors. We recommend that the Organization implement internal control procedures under the new payroll processes to ensure that documentation of supervisor approval of time sheets and subsequent payments is kept on file. Views of Responsible Officials and Planned Corrective Actions: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employees’ time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manager providing the final approval within ADP once all items are confirmed. This entire process is fully documented, with approvals recorded within ADP by employees and supervisors and the shared file drive where HR and Finance initial off on the reviewed payroll items, ensuring a traceable record of the entire payroll approval process.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale (repeated, prior two years 2023-101 and 2022-101) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), COVID-19 H8L50549 (2023), and COVID-19 H8G48569 (2022). Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. This has been a systemic issue as a repeat finding in the prior years. The sample was not statistically valid. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Thirteen of the sixty encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Health centers must prepare and apply a sliding fee discount schedule, so that the amounts owed for health center services by eligible patients are adjusted based on the patient's ability to pay (42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in 13 of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained in what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customary billing rates for all services until all documentation is received, or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025.
2024-104 Lack of Controls Related to Filing Reports (repeated, prior years 2023-104) (initially reported 2023) Assistance Listing Number: 93.224, 93.527 and 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program and Rural Telemedicine Grants Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), C1650381 (2023), COVID-19 H8L50549 (2023), COVID-19 H8G48569 (2022).GA142923 (2021) G2846293 (2022) and G3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $0 Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. In four of the reports selected for testing under ALN 93.224 and 93.527 two reports did not have documentation of approval by the CEO prior to submission. In three of the reports selected for testing under ALN 93.211 two reports did not have documentation of approval by the CEO prior to submission. This is a systemic issue that has been a finding in the previous year. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Cause: The Organization did not have a process in place for review of the data being reported on the HRSA website for the funds being expensed under the federal award programs. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be kept that clearly documents who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025.
2024-105 Lack of Payroll Review and Approval (repeated, prior year 2023-105) (initially reported 2023) Assistance Listing Number: 93.224, 93.527 and 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs, Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll, and the finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors’ approval of time recorded by employees. This is a systemic issue and has been a finding in the previous year. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards The requirement is for the Organization to have a process in place to correctly calculate, record, and pay payroll related expenses in accordance with grant and program requirements. Cause: The Organization does not have an effective process to review, approve, and document the supervisor’s approvals prior to making the payments. Effect: This situation provides an opportunity for errors and unauthorized transactions to occur and not be detected in a timely manner resulting in payroll expenses to be charged incorrectly to the federal awards. Recommendation: In April 2024, the Organization began using a third-party service provider to process payroll resulting in new control processes over the approval of time sheets by supervisors. We recommend that the Organization implement internal control procedures under the new payroll processes to ensure that documentation of supervisor approval of time sheets and subsequent payments is kept on file. Views of Responsible Officials and Planned Corrective Actions: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employees’ time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manager providing the final approval within ADP once all items are confirmed. This entire process is fully documented, with approvals recorded within ADP by employees and supervisors and the shared file drive where HR and Finance initial off on the reviewed payroll items, ensuring a traceable record of the entire payroll approval process.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale (repeated, prior two years 2023-101 and 2022-101) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), COVID-19 H8L50549 (2023), and COVID-19 H8G48569 (2022). Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. This has been a systemic issue as a repeat finding in the prior years. The sample was not statistically valid. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Thirteen of the sixty encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Health centers must prepare and apply a sliding fee discount schedule, so that the amounts owed for health center services by eligible patients are adjusted based on the patient's ability to pay (42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in 13 of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained in what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customary billing rates for all services until all documentation is received, or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025.
2024-104 Lack of Controls Related to Filing Reports (repeated, prior years 2023-104) (initially reported 2023) Assistance Listing Number: 93.224, 93.527 and 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program and Rural Telemedicine Grants Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), C1650381 (2023), COVID-19 H8L50549 (2023), COVID-19 H8G48569 (2022).GA142923 (2021) G2846293 (2022) and G3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $0 Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. In four of the reports selected for testing under ALN 93.224 and 93.527 two reports did not have documentation of approval by the CEO prior to submission. In three of the reports selected for testing under ALN 93.211 two reports did not have documentation of approval by the CEO prior to submission. This is a systemic issue that has been a finding in the previous year. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Cause: The Organization did not have a process in place for review of the data being reported on the HRSA website for the funds being expensed under the federal award programs. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be kept that clearly documents who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025.
2024-105 Lack of Payroll Review and Approval (repeated, prior year 2023-105) (initially reported 2023) Assistance Listing Number: 93.224, 93.527 and 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs, Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll, and the finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors’ approval of time recorded by employees. This is a systemic issue and has been a finding in the previous year. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards The requirement is for the Organization to have a process in place to correctly calculate, record, and pay payroll related expenses in accordance with grant and program requirements. Cause: The Organization does not have an effective process to review, approve, and document the supervisor’s approvals prior to making the payments. Effect: This situation provides an opportunity for errors and unauthorized transactions to occur and not be detected in a timely manner resulting in payroll expenses to be charged incorrectly to the federal awards. Recommendation: In April 2024, the Organization began using a third-party service provider to process payroll resulting in new control processes over the approval of time sheets by supervisors. We recommend that the Organization implement internal control procedures under the new payroll processes to ensure that documentation of supervisor approval of time sheets and subsequent payments is kept on file. Views of Responsible Officials and Planned Corrective Actions: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employees’ time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manager providing the final approval within ADP once all items are confirmed. This entire process is fully documented, with approvals recorded within ADP by employees and supervisors and the shared file drive where HR and Finance initial off on the reviewed payroll items, ensuring a traceable record of the entire payroll approval process.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.