Program Information: U.S. Department of Housing and Urban Development Indian Housing Block Grant Assistance Listing #14.867 Award Numbers: 55-IH-53-18320 Award Period: 10/18/2011 – 09/30/2034 Criteria: Per the 2024 OMB Compliance Supplement, each recipient shall develop written policies governing the eligibility, admission, and occupancy of families for housing assisted with grant funds (25 USC 4133(d)). Per YNHA policies, all program applicants must meet the following eligibility requirements: • Qualify as an Indian Family or qualify for an exception - YNHA may decide to provide housing assistance for non-Indian family if they deem the presence of the family on the reservation is essential to the well-being of Indian families and the need for housing of essential families cannot reasonably be met without such assistance (ex. teachers, healthcare providers). Executive Director will make a determination for essential families. YNHA may also provide housing for law enforcement officers of the Nation or another unit of government and YNHA determines the presence of the officer may deter crime. • Have an annual income that meets income eligibility standards (considered low-income based on HUD thresholds) or qualify as an exception. Families that are not low-income can receive assistance in a few cases: they were low income at the time of initial occupancy, they received a Mutual Help unit through transfer of the unit from a family member, or the family is an essential family/law enforcement (see above). • Be 18 years or older or 16 with status as an emancipated minor. • Provide a complete application including proof of tribal enrollment, social security cards, and proof of income. • Signed Consent for Release of Information to YNHA/HUD Form 9886. • Must submit to drug and alcohol screening tests prior to signing the rental agreement, lease, or homeownership agreement. • Annual inspections. 2 CFR § 200.303 - Internal controls states, 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). Condition/Context: During testing of 30 tenant files under the IHBG program: • 2 of 30 files did not include a signed rental agreement documenting initial eligibility approval. • 30 of 30 files lacked evidence of approval of recertifications or required inspections. [ X ] Compliance Finding [ ] Significant Deficiency [ X ] Material Weakness Cause: YNHA’s internal control procedures over eligibility and recertification were not consistently followed. Management did not ensure that signed agreements and approvals of recertifications/inspections were documented in the tenant files. Effect: Failure to document eligibility determinations and approvals creates a risk that ineligible tenants may receive housing benefits, that federal program requirements may not be met, and that YNHA may be subject to HUD compliance findings. Questioned Cost: N/A – The documentation deficiencies identified did not result in known unallowable costs or payments to ineligible participants; therefore, no questioned costs are reported. Prior Year Finding: No. Recommendation: We recommend that YNHA implement written procedures and staff training to ensure all required eligibility and occupancy documentation is obtained and retained. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: U.S. Department of Housing and Urban Development Indian Housing Block Grant Assistance Listing #14.867 Award Numbers: 55-IH-53-18320 Award Period: 10/18/2011 – 09/30/2034 Criteria: Non-federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR part 200. Non-federal entities other than states, including those operating federal programs as subrecipients of states, must follow the suspension and debarment standards set out at 2 CFR Part 180, which implements Executive Orders 12549 and 12689, “Debarment and Suspension,” federal awarding agency regulations in Title 2 of the CFR adopting/implementing the OMB guidance in 2 CFR Part 180; program legislation; and the terms and conditions of the award. 2 CFR § 200.303 - Internal controls states, 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). Condition/Context: 2 of 4 samples selected for suspension and debarment testing did not have documentation of a suspension and debarment search performed prior to entering a transaction with the vendor. [ X ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: There were ineffective controls in place during the period, along with management oversight. Effect: YNHA may unknowingly enter into business with a suspended or debarred vendor. Questioned Cost: N/A – While documentation of the suspension and debarment verification was not available, no evidence was identified indicating that payments were made to suspended or debarred parties. Therefore, no questioned costs were identified. Prior Year Finding: No. Recommendation: We recommend YNHA conduct a training for staff and program managers to review YNHA’s suspension and debarment requirements and perform searches annually. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: U.S. Department of Housing and Urban Development Indian Housing Block Grant Assistance Listing #14.867 Award Numbers: 55-IH-53-18320 Award Period: 10/18/2011 – 09/30/2034 Criteria: Per the 2024 OMB Compliance Supplement: Program regulations provide that a tribe may assume responsibilities for environmental review and decision making under the requirements of 24 CFR Part 58 or it may allow HUD to retain these responsibilities. The tribe is the responsible entity, whether or not a TDHE is authorized to receive IHBG grant amounts on behalf of the tribe (24 CFR section 58.2(a)(7)(ii)). If HUD retains the responsibilities, HUD will do reviews under the provisions of 24 CFR Part 50 (24 CFR section 1000.20). A HUD environmental review must be completed for any activities not excluded before a recipient may acquire, rehabilitate, convert, lease, repair, or construct property, or commit HUD or local funds (24 CFR section 1000.20(a)). If the tribe assumes these responsibilities, the following applies: An environmental review must be prepared for each project or activity. Funds may not be committed to a grant activity or project before the completion of the environmental review and approval of the Request for Release of Funds (RROF) and environmental certification. If the responsible entity tribe determines that it met a criterion specified in the regulations that would qualify the project as exempt or qualify the project for certain categorical exclusions, the RROF and environmental certification requirements do not apply (24 CFR sections 58.34 and 58.35(b), 24 CFR section 1000.20(b)(3)). 2 CFR § 200.303 - Internal controls states, 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). Condition/Context: During testing, we noted that 1 of 3 environmental review samples had expenditures prior to approval of the environmental review. [ X ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: Lack of internal controls over environmental reviews. Effect: If funds are expended prior to completion of the environmental review, they may be in violation of environmental laws and out of compliance with the program. The funds may also be used for projects where the review determines there were significant or unavoidable environmental impacts, and it should not have started. Questioned Cost: N/A – Although expenditures were incurred prior to approval of the environmental review, the costs tested were ultimately allowable under the program, supported by adequate documentation, and not prohibited by regulation. Therefore, no costs required adjustment or repayment. Prior Year Finding: No. Recommendation: We recommend YNHA ensure environmental reviews are approved prior to beginning work on the project. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Condition: In accordance with 2 CFR-200.328 and 2 CFR-200.303, non-federal entities must submit performance and financial reports as required by the awarding agency and must establish and maintain effective internal control over compliance with federal statutes, regulations, and the terms and conditions of the federal award. Context: The City is required to submit monthly progress reports ten calendar days after the end of each month, quarterly progress reports no later than the 10th of quarter end, and a bi-annual Contract and Subcontract Activity form (HUD-2516), to be submitted by April 15 and October 15 each year. Per testing, monthly and quarterly reports were submitted 10 to 27 days after the deadline. ABPA was unable to obtain evidence that form HUD-2516 was submitted by either of the required due dates. Effect: Failure to submit required reports in a timely manner, and the lack of supporting documentation, represents a deficiency in internal control over compliance. This increases the risk of noncompliance with federal reporting requirements, which could result in questioned costs, delayed reimbursements, or jeopardize future funding. Cause: Delays in report submission were primarily due to insufficient internal controls over the reporting process, lack of clear assignment of responsibilities, and inadequate monitoring of reporting deadlines. Questioned costs: None. Recommendation: We recommend that the City strengthen its internal controls over compliance by implementing a centralized reporting calendar or system to monitor federal reporting deadlines. In addition, procedures should be established to ensure that documentation of timely report submission is retained in the grant files. Staff responsible for grant administration should also receive training on federal reporting requirements.
Assistance Listing Number: 97.036 Program Title: Disaster Grants-Public Assistance (Presidentially Declared Disasters) Compliance Requirement: Reporting - Performance Reporting Pass-through Entity: Florida Division of Emergency Management Federal Grant/Contract Number and Grant Year: Z0884 2019 Finding Type: Material Weakness in Internal Control and Compliance Known Questioned Costs: $0 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. Federal awards submitted to the federal awarding agency should include all the activity of the reporting period, are supported by the underlying accounting or performance records, and are fairly presented in accordance with program. Condition: Of the 40 quarterly Federal Emergency Management Agency reports included in our sample for testing, 3 of the reports prepared by the County’s consultant were not based on the approved expenses and the underlying supporting documentation. This was not a statistically valid sample. Cause: The County has not implemented procedures to formally document their review of the quarterly reporting prior to submission of those reports by their third-party consultant to the Florida Division of Emergency Management which would have been able to detect these errors. Effect: Quarterly reporting could include potential errors and cause the County to be out of compliance with the requirements of the grant. Recommendation: The County should implement formal documentation via signature of approval on the quarterly reporting prior to submission to the Florida Division of Emergency Management. Management Response: See attached Corrective Action Plan.
Assistance Listing Number: 97.083 Program Title: Staffing for Adequate Fire and Emergency Response Grant (SAFER)Compliance Requirement: Cash Management Pass-through Entity: N/A - Direct Federal Grant/Contract Number and Grant Year: EMW-2019-FF-01635 2019 Finding Type: Material Weakness in Internal Control and Compliance Known Questioned Costs: $0 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. Condition: Of the three reimbursement requests selected for testing, two reimbursement requests had ineligible payroll costs approved for reimbursement by the Grant Administrator. This was not a statistically valid sample. Cause: Errors in the completion of the report by the Grant Administrator and inadequate review of the reports by the County which would have detected these errors. Effect: In both instances, the grantor caught the ineligible costs submitted for reimbursement and only reimbursed the eligible payroll costs. However, this could have been a much more significant issue if the grantor had not caught these ineligible costs which would then have caused the County to be out of compliance with the requirements of the grant. Recommendation: The County should implement an additional review of the payroll costs submitted with the reimbursement request. Review should be documented via signature of approval prior to submission or formal email confirmation that a review was done and the reimbursement request may be submitted. Management Response: See attached Corrective Action Plan.
Program: ALN 84.425V, Department of Education, Education Stabilization Fund, Emergency Assistance to Non-Public Schools, passed through the State of Alaska, grant number CO23.244.01/1004 052132102 2211Criteria: 2 CFR section 200.303(d)(2), states that a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statues, regulations, and the terms and conditions of the federal award. 2 CFR section 200.430(g)(1), states that charges to Federal awards for salaries and wages must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Condition: SAAMS’ policies require a payroll batch report be reviewed prior to issuing payroll. This payroll batch report specifies employee name, program charged, amount charged to each program, hours, and pay rate. During our testing, we identified that the payroll batch report did not always contain amounts charged to each program or pay rates, making the review ineffective. Cause: Turnover in personnel during the fiscal year led to inadequate training and inconsistent performance of the payroll batch report review. Effect: Unallowable payroll costs may be charged to a federal program. Questioned costs: None Context: During our testing of 11 payroll batch reports, 5 did not contain pay rates or amounts charged to each program. Statistical sampling: No Repeat finding: No Recommendation: We recommend the entity develop policies that incorporate standardized reporting and description of the review objective, along with training to staff.
Program: ALN 11.012, National Oceanic and Atmospheric Administration, Implementation and Development of Regional Coastal Ocean Observing System, Alaska Ocean Observing System grant numbers NA16NOS0120027, NA21NOS0120094, NA23NOS0120080, NA24NOSX012C0027 Criteria: 2 CFR section 200.303(d)(2), states that a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statues, regulations, and the terms and conditions of the federal award. Condition: Reports were submitted to the federal agency without documented review or approval by management. Cause: The entity contracts with another organization to act as its fiscal agent. The fiscal agent experienced significant turnover and delays in hiring qualified personnel for finance roles, and the entity did not retain documentation of report reviews. Possible asserted effect: Lack of review increases the risk of submitting incomplete or inaccurate information, potentially leading to audit findings or questioned costs. Questioned costs: None Context: Inspection of all reports submitted during the year indicated that no financial or performance reports had documented approval prior to submission. Statistical sampling: No Repeat finding: No Recommendations: We recommend the entity work with its fiscal agent to provide oversight and compensating controls in times of staff vacancy, and develop policies that incorporate review and documentation of review of reports prior to them being submitted to the granting agencies. Views of responsible officials: AOOS will work with its fiscal agent to strengthen oversight and establish compensating controls during staff vacancies to ensure proper review of reports. In addition, AOOS will develop and implement policies that require management review and documentation of all reports prior to submission to granting agencies, thereby ensuring accuracy, accountability, and compliance with federal requirements
Finding 2024-001: Payroll Accruals - Material Weakness in Internal Controls over Financial Reporting and Internal Control over Federal Programs and Compliance Finding Federal Agency(ies): United States Agency for Global Media Federal Program(s): International Broadcasting Independent Grantee Organizations Assistance Listing Number(s): 90.500 Pass-through Entity (if applicable): N/A Award Identification Number and Year: MN01-24-GO-00001 (2024) Criteria or Specific Requirement: The general standards for internal controls over financial reporting set forth the objective of a system of internal control that provides for management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct misstatements on a timely basis. Additionally, 2 CFR 200.303 Internal Controls states that recipients must establish, document, and maintain effective internal control 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. These internal controls should align with the 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: Prior to the start of our audit, the Organization noted that they had gone through an extensive balance sheet account cleanup process but had a few balance sheet accounts that had not yet been reconciled or cleaned and they were aware of adjustments that still needed to be made, but with the reduction in staff had not been able to address. The largest balance of these remaining accounts was the payroll accruals. As such, the Organization had not yet accrued payroll expenditures for the final pay period of the fiscal year. Additionally, it was confirmed that accrued payroll balances presented in the preliminary trial balance were related to prior year activity that was not accounted for properly. Such balances were adjusted during the audit, and a restatement of the opening net deficit was posted. Cause: At the end of the 2024 fiscal year, the Organization was in the midst of a restructuring, and did not have adequate resources in place in the finance and accounting department to properly review and reconcile the year end payroll accruals. This has now been corrected through the audit process. Effect or Potential Effect: Material errors with respect to year payroll accruals increase the risk that the financial statements as a whole, as well as the expenditures reported to USAGM, will not be presented correctly and also impacts the ability of management to make accurate financial decisions. However, the Organization knew what the correct balance should be so the ability to make accurate financial decisions was not impacted. Questioned Costs: NoneContext: The misstatement attributable to missed September 2024 payroll accruals was an understatement of expenses of approximately $2.48 million. The misstatement attributable to prior year activity was approximately $1 million (an increase in the net deficit). Identification as a Repeat Finding, if Applicable: Repeat of Finding 2023-001 and 2023-002 Recommendation: We recommend that management devote additional resources to the accounting and finance team to provide capacity for the implementation of thorough review and reconciliation process during year-end close.
(a) Criteria or Requirement 2 CFR 200.303 requires non-federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Effective internal control should include procedures to ensure federal expenditures are accurately and completely reported on the SEFA. (b) Condition Found The System lacked sufficient internal controls to ensure the allowability of expenditures charged to the HIV Care Formula Grants. Our testing of a sample of 40 transactions totaling $6,054 identified three charges, totaling $488, that were incorrectly billed to the federal program. These costs, although related to services provided to patients, were determined unallowable for the following reasons: • The patients had other insurance coverage that was not billed prior to submission to the federal agency. • The patients did not meet all eligibility requirements and should have been excluded from reimbursement requests. Additionally, management did not maintain adequate documentation to support the annual reverification of patient eligibility, which is required prior to receiving services each year to remain eligible for the program. Due to these deficiencies, an expanded sample of 23 additional charges totaling $2,799 was tested. Of these,12 were determined to be unallowable, totaling $1,808. Charges related to certain costs related to July through September 2024 were related to an agreement that was not fully executed, resulting in an additional $97,782 of unallowable costs. Lastly, management did not retain sufficient supporting documentation for certain amendments to the grant agreement. This documentation is necessary to substantiate various elements of patient eligibility criteria under the grant. The grant amendment includes specific language that the grant is for the treatment of females over the age of 13, however both males and females were expensed and reimbursed under the grant. The male population for the remaining nine months of year represents $404,710. Our testing identified 26 out of our expanded sample of 63 total patients were males that were not also identified in the above testing results, totaling $3,835. (c) Cause The System’s review processes for charges recorded against the grant and submitted for federal reimbursement were ineffective in preventing unallowable charges and inaccurate amounts.. NORTH MISSISSIPPI HEALTH SERVICES, INC. Schedule of Findings and Questioned Costs Year ended September 30, 2024 54 DRAFT 10/18/2025 10:56 AM 694078F-1A_NorthMississippiHealthServicesInc_SACR.docx Additionally, the System could not provide documentation for certain grant agreement amendments that would have supported the eligibility of specific patients. (d) Effect Federal funds were expended for unallowable purposes or for inaccurate amounts and evidence of the effective operation of management review controls was not maintained in accordance with Federal requirements. (e) Questioned Cost Expenditures related to patient charges of $222,016. (f) Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. (g) Repeat Finding in the Prior Year Not a repeat finding (h) Recommendation We recommend that the System strengthen controls over the management review process to prevent unallowable costs and inaccurate amounts from being charged to Federal programs as well as ensure all relevant documentation is maintained in accordance with Federal requirements. (i) View of Responsible Officials Invoices were submitted to Mississippi State Department of Health (MSDH) for the HIV Care Formula Grants (CFDA No. 93.917); however, clinic staff did not conduct a thorough evaluation to verify continued eligibility for the program among patients who had previously qualified. Additionally, the lack of a fully executed agreement was a management oversight which contributed to the uncertainty regarding allowable billing to the program for reimbursement. Supporting documentation, including paperwork and emails, was also not properly maintained by management
2024-002 Suspension and Debarment ALN 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Department of the Treasury Grant # Y5082 2021 funding Condition: City staff were unable to produce contemporaneous documentation of verification that vendors were not disqualified, excluded, or debarred prior to entering into a covered transaction. Criteria: 2 CFR 180.300 requires the City to ensure vendors and contractors are not disqualified, excluded, or debarred prior to entering into a covered transaction. 2 CFR 200.303 requires non-federal entities to establish and maintain effective internal controls. The City should have a process to ensure compliance with 2 CFR 180.300. Cause: The City has experienced significant turnover in key management positions, including the City Manager and Finance Director, which created obstacles to locating documentation from prior periods. Potential Effect of Condition: Without a prior SAM check the City may have covered transactions with federally debarred vendors. However, in this case the impacted vendor was not debarred so there were no instances of non-compliance. Questioned Costs: None. Perspective: Of the non statistical sample of two vendors, one of the vendors did not have verification of not being suspended or debarred. Recommendation: The City should perform SAM checks for all vendors or contractors prior to entering into covered transactions and retain documentation of these processes. Management Response: Management concurs with the recommendation. The City recognizes the importance of complying with 2 CFR 180.300 and 2 CFR 200.303 to ensure that vendors and contractors are not suspended, debarred, or otherwise excluded from participation in federally funded programs. To strengthen compliance and documentation going forward, the City will implement the following corrective actions: 1. Establish a Standardized SAM Verification Process: The City will formalize written procedures requiring verification of all vendors and contractors in the System for Award Management (SAM) prior to entering into any covered transaction. 2. Maintain Documentation: Copies or screenshots of SAM verifications will be retained in the vendor file and/or attached within the City’s financial management system to ensure documentation is readily available for audit purposes. 3. Designate Responsibility: The Finance Department will assign a staff member to perform and document the SAM verification process, with supervisory review prior to vendor approval. 4. Provide Staff Training: Relevant staff will receive training on federal procurement requirements, including SAM verification procedures and documentation standards. 5. Ongoing Monitoring: Management will periodically review vendor files to confirm compliance with these requirements and ensure documentation is properly maintained. Management expects these measures will strengthen internal controls, ensure continued compliance with federal regulations, and prevent similar documentation issues in future audits.
Criteria 2 CFR 200.303 requires that the non-Federal entity must "(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in "Standards for Internal Control in the Federal Government" issued by the comptroller General of the United States and the "Internal Control Intergrated Framework", issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)." Uniform Guidance 2 CFR Section 200.320 (a)(2) states regarding the applicability of simplified acquisition procedures: "The aggregate dollar amount of the procurement transaction is higher than the micro purchase threshold but does not exceed the simplified acquisition threshold. If simplified acquisition procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources. Unless specified by the Federal agency, the recipient or subrecipient may exercise judgment in determining what number is adequate." Per procurement policy of AIHEC requires that for procurement by small purchase ($10,000 - $249,000), where the aggregate dollar amount is higher than the micro-purchase threshold, price or rate quotations must be obtained from three qualified sources. If three separate qualified sources cannot be obtained the reason needs to be formally documented. Condition/Context For procurement transaction tested, we noted that AIHEC did not complete a sole-source justification form timely to support the vendor that was selected. Cause Management does not have sufficient internal controls in place to ensure that AIHEC's procurement policies are followed for all procurement transactions prior to entering the procurement. Effect AIHEC entered into a procurement that did not go through a competitive solicitation process. Recommendation Management should review its policies and procedures to ensure all procurement transactions are in accordance with AIHEC's procurement policies and have the appropriate supporting documentation.
Finding 2024-002: Insufficient Documentation of Management Review of Section 3 Quarterly and Annual Reporting Audit Finding: Significant Deficiency Federal Program: Community Development Block Grant Mitigation Program Citywide Drainage Improvements (Assistance Listing 14.228) Compliance Requirement: Reporting and Special Tests and Provisions – Section 3 Requirements Criteria: In accordance with Title 2 of the Code of Federal Regulations (2 CFR) § 200.303, the City must establish and maintain effective internal controls over federal awards that provide reasonable assurance of compliance with federal statutes, regulations, and the terms and conditions of the award. Additionally, 2 CFR § 200.328 requires the City to ensure that reports submitted to the pass-through entity are accurate, complete, and supported by adequate review and oversight. The U.S. Department of Housing and Urban Development’s (HUD) Section 3 regulations at 24 CFR Part 75 require recipients to prepare and submit quarterly and cumulative annual Section 3 reports documenting efforts to provide employment, training, and contracting opportunities to low- and moderate-income persons and businesses within the project area. Condition: The City’s grant administrator is responsible for preparing and submitting the required quarterly and annual Section 3 reports to the Texas General Land Office on behalf of the City. However, there is no documentation demonstrating that City management reviews or approves these reports prior to and after submission. Cause: The City has not established procedures requiring City management to review and document approval of the Section 3 reports prepared and submitted to the Texas General Land Office. Effect: Without documentation of City management review and approval of the Section 3 reports prepared and submitted by the grant administrator, there is an increased risk that reports submitted to the passthrough entity may be inaccurate, incomplete, or not fully compliant with federal reporting requirements. Questioned Costs: None noted. Recommendation: The City should strengthen internal controls over federal reporting by establishing and documenting procedures to ensure City management reviews and approves all Section 3 reports prepared and submitted by the grant administrator. Evidence of this review, such as sign-offs or approval correspondence, should be retained in the grant files to demonstrate compliance with Uniform Guidance and HUD Section 3 reporting requirements. View of Responsible Officials: Management concurs with the recommendation. Please refer to the Corrective Action Plan for additional details.
Federal Program: Community Development Block Grants – Non Entitlement (Assistance Listing 14.228) Criteria: In accordance with Title 2 of the Code of Federal Regulations (2 CFR) § 200.303, the City must establish and maintain effective internal controls over federal awards that provide reasonable assurance of compliance with federal statutes, regulations, and the terms and conditions of the award. Additionally, 2 CFR § 200.328 requires the City to ensure that reports submitted to the pass-through entity are accurate, complete, and supported by adequate review and oversight. The U.S. Department of Housing and Urban Development’s (HUD) Section 3 regulations at 24 CFR Part 75 require recipients to prepare and submit quarterly and cumulative annual Section 3 reports documenting efforts to provide employment, training, and contracting opportunities to low- and moderate-income persons and businesses within the project area. Condition: During single audit testing for reporting, it was noted that management could not provide documentation for review of performance and Section 3 reports for the Community Development Block Grant – State’s Program grant. The grant administrator performs and submits all required reports. Cause: The City has not established procedures requiring City management to review and document approval of the Section 3 reports prepared and submitted to the Texas General Land Office. Effect or Potential Effect: The absence of documented reviews increases the risk that errors or irregularities in financial reporting or compliance with federal program requirements may not be detected and corrected in a timely manner. Recommendations: The City should strengthen internal controls over federal reporting by establishing and documenting procedures to ensure City management reviews and approves all Section 3 reports prepared and submitted by the grant administrator. Evidence of this review, such as sign-offs or approval correspondence, should be retained in the grant files to demonstrate compliance with Uniform Guidance and HUD Section 3 reporting requirements. Repeat Finding: No Views of Responsible Officials: See Corrective Action Plan.
Finding 2024-001 (A/B – Activities Allowed or Unallowed and Allowable Costs / Cost Principles) Identification of the federal program: Federal Grantor: US Department of Homeland Security Federal Emergency Management Agency (FEMA) Assistance Listing No.: 97.036 - COVID-19 - Disaster Grants – Public Assistance (Presidentially Declared Disasters) Criteria or specific requirement (including statutory, regulatory or other citation): The Uniform Guidance 2 CFR section 200.303 states, “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).” The Uniform Guidance 2 CFR sections 200.400 through 200.405 set forth the guidance for allowable costs for projects funded with Federal funds. Condition: Baptist Health Care, Inc. (the Company) received funding under program 97.036 – COVID-19 - Disaster Grants – Public Assistance (Presidentially Declared Disasters) (Program) during the fiscal year ended September 30, 2024. The Company submitted duplicate invoices for different projects that resulted in expenditures being reimbursed for costs incurred multiple times. The Company also submitted for reimbursement an amount greater than what was supported by the underlying invoice due to incorrect data submission. Based on discussions with management, we understand that the Company utilized a contracted third party to assist with collecting the information to be submitted to FEMA. However, the internal controls over compliance did not detect or prevent these situations from occurring at the required level of precision. As such, we consider the lack of effectiveness of controls to validate completeness and accuracy of the amounts submitted for reimbursement for this program to represent a material weakness in internal control over compliance. Cause: The Company’s internal controls in place over the review of the completeness and accuracy of amounts submitted for reimbursement under the Program were not sufficient to detect or prevent errors in the underlying files submitted for reimbursement. Effect or potential effect: The lack of management review at a sufficient level of precision regarding expenditures submitted for reimbursement under this Program resulted in the reimbursement of duplicate invoices and reimbursement of an amount greater than the amount supported by the underlying supporting documentation from the granting agency. As a result, the Company will be required to reimburse the Federal Agency. Questioned costs: $79,118.82 Context: There were 8 individual projects for the COVID-19 disaster that the Company received funding for in fiscal year 2024. These projects were submitted to FEMA during the fiscal years 2020 through 2022. We selected 40 expenditures totaling $161,579 from the total population of expenditures totaling $1,843,741. We identified a duplicate invoice in our testing sample. We then reviewed the total population of invoices subject to testing and identified 24 invoices totaling $77,521.50 that were submitted for reimbursement more than once and therefore reimbursed by the Program more than once. We also identified one invoice totaling $177.48 for which reimbursement was requested for an amount $1,597.32 greater than the invoice amount. We extrapolated this error to estimate the likely questioned costs of $16,629.33. We reviewed the entire population of expenditures for which reimbursement was requested and received to determine the total amount of duplicate reimbursements and reimbursements in excess of supporting documentation to quantify the total known questioned costs of $79,118.82. Identification as a repeat finding, if applicable: Not applicable. Recommendation: The Company should ensure that a diligent review of amounts submitted for reimbursement is conducted at a sufficient level of precision by an appropriate individual with knowledge of the Program to ensure expenditures are only submitted once for reimbursement and to ensure that amounts submitted for reimbursement are not in excess of the amounts supported by appropriate documentation. We also recommend that management reimburse the Agency for the amounts reimbursed more than once and reimbursed at amounts in excess of the appropriate supporting documentation. Views of responsible officials: The Company agrees with the above recommendation. See separate Corrective Action Plan.
Finding 2024-043 - Use of Federal Funds to Satisfy Required Local Match Without Prior Approval Summary: The City of Batesville substituted federal Delta Regional Authority (ORA) and Appalachian Regional Commission (ARC) funds for required local match obligations under two federal grants-ARC (ALN 23.002) and CDBG (ALN 14.228)-without obtaining prior written approval from the awarding agencies. Although CDBG was not selected for audit testing, the questioned costs originally exceeded the $10,000 threshold and are reported in accordance with 2 CFR §200.516(a): Total questioned costs of $800,406 were initially allocated proportionally between the two programs; These costs have since been resolved through formal amendments to both grant agreements. Federal Programs 23.002 _; Appalachian Area Development (ARC) 14.228 - Community Development Block Grants/State's Program and Non-Entitlement Grants in Hawaii· (CDBG) Note: ALN 14.228 was not selected for audit testing under the Uniform Guidance compliance requirements. However, a finding is presented in accordance with 2 CFR §200.516(a) due to the materiality of the issue and its connection to ARC grant MS-20699. Award Numbers ARC: MS-20699 CDBG Subgrant: 1137 ~21-111-PF-01 Federal Agencies U.S. Department of the Treasury (via Appalachian Regional Commission) U.S. Department of Housing and Urban Development Compliance Requirements Matching - 2 CFR §200.306 Allowable Costs/Cost Principles - 2 CFR §200.403 Internal Controls -2 CFR §200.303 Audit Finding Threshold - 2 CFR §200.516(a) Type of Finding Internal Control over Compliance - Material Weakness Compliance - Noncompliance Questioned Costs Based on actual net expenditures and proportional match requirements: (TABLE) These questioned costs have been eliminated following receipt of amended contracts from ARC and CDBG approving the use of ORA and CDBG funds as match. Criteria The following federal regulations and grant conditions establish the requirements violated in this finding: 1. Matching Requirements - 2 CFR §200.306 Federal funds may not be used to meet a required cost share or match unless expressly authorized by the awarding agency. Matching contributions must: Be verifiable from the recipient's records Not be included as contributions for any other federal award Be necessary and reasonable for accomplishing program objectives Be allowable under the cost principles Not be paid by. the federal government under another award, unless authorized 2. Allowable Costs ... 2 CFR §200.403 Costs must be necessary, reasonable, allocable, and conform to limitations in the award terms. Costs must be adequately documented and consistent with policies that apply uniformly to both federally financed and other activities. 3. Internal Controls - 2 CFR §200.303 Recipients must establish and maintain effective internal controls to ensure compliance with feqeral statutes, regulations, and award terms. Controls should provide reasonable assurance that the organization is managing the award in compliance with applicable requirements. 4. Audit Finding Threshold-2 CFR §200.516(a) Auditors must report known questioned costs that exceed $10,000 for a federal program, even if the program was not selected for audit testing. Condition During the audit of ARC grant MS-20699 (ALN 23.002), we noted that the City of Batesville substituted $569,600 in federal ORA funds for the originally budgeted local match of $341,784. Additionally, for COBG grant ALN 14.228, the City substituted $569,600 in ORA funds and $553,000 in ARC grant funds for the originally budgeted local match of $901,784. These substitutions were made without prior written approval or executed amendments from the awarding agencies, as required under 2 CFR §200.306 and the respective grant agreements. Resolution Following the audit fieldwork, the City obtained formal amendments to both grant agreements: On October 24, 2025, ARC approved the substitution of ORA and COBG funds as match under ALN 23.002. On November 7, 2025, COBG approved the substitution of ORA and ARC funds as match under ALN 14.228. These approvals eliminate the previously identified questioned costs totaling $800,406. However, the lack of contemporaneous documentation and prior approval reflects a breakdown in internal controls and remains a material compliance issue. Cause The City lacked adequate internal controls to ensure changes to match sources were formally reviewed and approved by the awarding agencies prior to implementation. The substitution of federal funds for required local match was not documented or authorized at the time of expenditure. Effect Although questioned costs have been resolved, the City was in noncompliance with federal matching requirements and allowable cost principles at the time of expenditure. This reflects a broader control deficiency in the City's grant management process and increases the risk of future noncompliance. Recommendation We recommend the City strengthen its internal controls over grant compliance, including: Formal review and documentation of match sources prior to drawdown Written approval from awarding agencies before substituting federal funds for required match Staff training on federal match requirements and Uniform Guidance compliance Views of Responsible Officials Management concurs with the finding. The City acknowledges that federal ORA and ARC funds were applied toward required match obligations without prior approval or amendment to the respective grant agreements. ARC and CDBG representatives have since approved the substitutions through formal amendments. The City will implement procedures requiring written authorization for any future match substitutions and establish a formal review process to verify match sources prior to drawdown.
2024-032 - Delayed Final Reimbursement Due to Unresolved Agency Requests Federal Programs 23.002 - Appalachian Area Development 14.228 - Community Development Block Grants/State's Program Award Numbers ARC-20698 ARC-20699 CDBG Subgrant: 1137-21-111-PF-01 Federal Agency U.S. Department of Housing and Urban Development (HUD) Appalachian Regional Commission (ARC) Compliance Requirement Reporting and Closeout- 2 CFR §§ 200.302, 200.303, and 200.344 Type of Finding: Internal Control over Compliance - Significant Deficiency Compliance - Noncompliance Questioned Costs: None Criteria: In accordance with 2 CFR §200.302 and §200.303, non-federal entities must maintain effective internal control over federal awards and ensure timely closeout. Additionally, 2 CFR §200.344 requires that closeout be completed within one year of the end of the period of performance. Condition: Final reimbursement requests for the above federal programs were submitted over a year ago. Although the granting agencies have initiated follow-up correspondence requesting additional documentation or clarification, the final payments remain outstanding as of the audit date. No resolution has been reached, and the grants remain open. Cause: The City lacks a formalized process for tracking unresolved reimbursement requests and responding to agency inquiries in a timely and coordinated manner. This has contributed to delays in resolving outstanding issues and receiving final payments. Effect: The City has not received final reimbursement for completed federal programs, resulting in delayed revenue recognition and potential strain on local resources. The extended delay also risks noncompliance with federal closeout requirements and may affect future funding eligibility. Recommendation: Implement a grant closeout protocol that includes: A centralized tracking system for final reimbursement submissions and agency correspondence Defined timelines for follow-up and escalation Clear assignment of responsibility for resolving outstanding issues Views of Responsible Officials: Management concurs with the finding. The City acknowledges that final reimbursement requests for the referenced federal programs were submitted in a timely manner; however, final payments have not been received due to ongoing correspondence and requests for additional information from the granting agencies. While staff have responded to these inquiries, the absence of a formalized tracking and escalation process has contributed to delays in resolution.
2024-044 - Untimely Submission of Required Performance Reports Federal Programs 23.002 - Appalachian Area Development (ARC) Award Numbers ARC MS-20698 ARC MS~20699 Federal Agency Appalachian Regional Commission (ARC) Compliance Requirement Reporting - 2 CFR §200.328 and §200.303 Type of Finding Internal Control over Compliance - Significant Deficiency Compliance - Noncompliance Questioned Costs None. The reporting noncompliance did not affect the allowability of costs charged to the grant. Criteria 2 CFR §200.328(b)(1) requires recipients to submit performance reports at intervals required by the federal awarding agency or pass-through entity. These reports must contain a comparison of actual accomplishments to the objectives of the award and be submitted in accordance with the terms and conditions of the grant. 2 CFR §200.303 requires recipients 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. This includes controls over timely and accurate reporting. Under the ARC grant agreements, semi-annual performance reports are required to be submitted within 15 days following the end of each six-month reporting period. Condition The City did not submit required semi-annual performance reports for ARC grants MS-20698 and MS-20699 within the timeframes established by the grant agreements. Reports were submitted significantly past the 15-day deadline following the end of each six-month reporting period. In some cases, multiple reports were submitted on the same day, and one report due during the audit period had not been filed as of fieldwork completion. Additionally, the reports lacked clear identification of the reporting period covered. Cause The City did not have adequate procedures in place to ensure timely tracking and submission of required performance reports. Internal controls over reporting deadlines were not operating effectively. Effect Failure to submit timely and complete performance reports limits the pass-through entity's and federal awarding agency's ability to monitor project progress and ensure compliance with grant terms. This represents noncompliance with federal reporting requirements and a deficiency in internal control over federal programs. Recommendation We recommend the City implement procedures to ensure timely submission of required performance reports, including: Maintaining a reporting calendar with automated reminders Assigning responsibility for monitoring deadlines Retaining documentation that clearly identifies the reporting period covered Views of Responsible Officials Management concurs with the finding. The City acknowledges that performance reports were submitted late and that documentation lacked clarity regarding the reporting periods. To address this, the City will implement a reporting calendar with automated reminders and assign staff responsibility for monitoring deadlines. A standardized reporting template will be adopted to ensure each submission clearly identifies the reporting period covered. These measures will strengthen internal controls and improve compliance with ARC reporting requirements.
2024-042 - Misallocation of Expenditures Across Federal Awards Federal Program 14.228 - Community Development Block Grants Program 23.002 - Appalachian Area Development 90.210 - Delta Regional Authority (not subject to audit under Uniform Guidance) Award Numbers ARC-20698 ARC-20699 CDBG Subgrant: 1137-21-111-PF-01 Federal Agencies U.S. Department of Housing and Urban Development (HUD) U.S. Department of the Treasury (via Appalachian Regional Commission) Delta Regional Authority (DRA) Compliance Requirements Allowable Costs/Cost Principles - 2 CFR §200.403 and §200.405 Internal Controls - 2 CFR §200.303 Type of Finding Internal Control over Compliance - Significant Deficiency Compliance '- Noncompliance Questioned Costs (TABLE) Per 2 CFR §200.403, costs must be necessary, reasonable, and allocable to the federal award. Under §200.405, costs must be assigned to the federal award in accordance with the relative benefits received. Additionally, §200.303 requires the non-federal entity to maintain effective internal control over federal awards to ensure compliance. Condition During testing of 13 disbursements totaling $1,541,660 charged to the above federal programs, 11 invoices were not allocated in accordance with the approved budget percentages. This resulted in over-reimbursements across multiple federal awards. Known Over (Under) Reimbursements by Program and Fiscal Year (TABLE) *ALN 90.210 was not subject to audit under Uniform Guidance. Amounts shown are for context only. Cause The City did not consistently apply approved budget allocation percentages when charging expenditures to federal awards. This resulted in misclassification of costs and excess reimbursement from federal sources. Effect The City received federal reimbursements in excess of allowable amounts under ALNs 14.228 and 23.002. These errors may result in repayment obligations and indicate a broader weakness in internal controls over grant accounting and drawdown procedures. Recommendation We recommend the City strengthen its internal controls over grant accounting and reimbursement procedures. This should include: Formal review of allocation schedules prior to submission of reimbursement requests Periodic reconciliation of actual expenditures to approved budget allocations Staff training on federal cost principles and grant compliance requirements Views of Responsible Officials Management concurs with the finding. The City acknowledges that allocation errors occurred across multiple federal programs due to inconsistent application of approved budget percentages. To address this, the City will implement a formal review process for allocation schedules and establish reconciliation procedures to ensure expenditures align with approved budgets. Staff will receive training on federal cost principles and grant compliance requirements. The City will also evaluate prior reimbursements and consult with awarding agencies regarding any necessary adjustments.
Segregation of Duties Condition and criteria: During our audit of the Authority’s Schedule of Expenditures of Federal Awards, we noted that the Authority does not have adequate segregation of duties in place. Specifically, the same individual is responsible for initiating and recording journal entries and disbursements and reconciling the bank accounts. In accordance with 2 CFR § 200.303(a), 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. Cause and Effect: The Authority is a small entity with limited administrative and accounting staff, which makes it difficult to achieve a complete segregation of duties. Due to resource constraints, individual staff members are assigned multiple roles that overlap key financial processes. Without proper segregation of duties, there is an increased risk that errors or irregularities, including potential misappropriation of assets or fraud, could occur and remain undetected. This condition could lead to noncompliance with applicable federal requirements and inaccuracies in financial reporting. Auditor’s Recommendations: We recommend that the Authority assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the board or executive leadership, documentation of independent reviews, and rotation of duties when possible. Authority’s Response: The board reviews the reports monthly. A printed payroll report and checks written from meeting to meeting are provided and are approved and initialed. Also provided is a report of the bank statements for the board to review what has been received and what has been paid. Before any bills are paid they are approved at the meeting. If an error is made when inputting a deposit received into C/A, the correction is printed and initialed approving the correction.
Finding 2024-004: Allowable Costs Program Title: Defense Nuclear Nonproliferation Research Assistance Listing Number: 81.113 Federal Agency: U.S. Department of Energy Direct Award Identifying Numbers: DE-NA003862, DE-NA004179, DE-NA0004177 Federal Award Year: Year ended September 30, 2024 Program Title: Export Control and Related Border Security Assistance Listing Number: 19.901 Federal Agency: U.S. Department of State Direct Award Identifying Number: SAQMIP23CA0153 Pass-Through Entity Name, Pass-Through Identifying Number: The Research Foundation for SUNY, University at Albany, 3-98939 Federal Award Year: Year ended September 30, 2024 Type of Finding: Material Weakness in Internal Control over Compliance Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 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 over expenditures, we noted that there is no written documentation of the review and approval of transactions that are reimbursed by Federally funded awards. Cause: PFI does not have a formal policy in place with respect to documenting management’s review and approval over expenditures of Federal awards. As such, PFI did not have effective internal controls in place to ensure that approvals were performed and documented as being performed in a timely manner. Effect or Potential Effect: There is the potential that expenditures allocated to the Federal awards were not properly reviewed in a timely manner which could result in unallowable costs being charged to Federal awards and potential noncompliance. Questioned Costs: None. Context: 46 out of 46 salary and wage expenditure transactions and 60 out of 60 expenditure transactions selected for control testing did not have documented review and approval. The sample is deemed representative of the population. Repeat Finding: Not applicable. Recommendation: We recommend that PFI implement a formal expense review and approval policy. This policy should require that management formally document its review and approval all expense transactions on a timely basis.
Finding 2024-005: Period of Performance Program Title: Defense Nuclear Nonproliferation Research Assistance Listing Number: 81.113 Federal Agency: U.S. Department of Energy Direct Award Identifying Numbers: DE-NA003862, DE-NA004179, DE-NA0004177 Federal Award Year: Year ended September 30, 2024 Program Title: Export Control and Related Border Security Assistance Listing Number: 19.901 Federal Agency: U.S. Department of State Direct Award Identifying Number: SAQMIP23CA0153 Pass-Through Entity Name, Pass-Through Identifying Number: The Research Foundation for SUNY, University at Albany, 3-98939 Federal Award Year: Year ended September 30, 2024 Type of Finding: Material Weakness in Internal Control over Compliance Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 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 over expenditures, we noted that there is no written documentation of the review and approval of transactions that are reimbursed by Federally funded awards. Cause: PFI does not have a formal policy in place with respect to documenting management’s review and approval over expenditures of Federal awards. As such, PFI did not have effective internal controls in place to ensure that approvals were performed and documented as being performed in a timely manner. Effect or Potential Effect: There is the potential that expenditures allocated to the Federal awards were not properly reviewed in a timely manner and could have been charged to a Federally funded award outside of the grant’s stated period of performance, thereby creating a potential for being reimbursed for unallowable costs. Questioned Costs: None. Context: 3 out of 3 grants under ALN 81.113 and 2 out of 2 grants under ALN 19.901 selected for control testing did not have documented review and approval for their expenditures. The sample is deemed representative of the population. Repeat Finding: Not applicable. Recommendation: We recommend that PFI implement a formal expense review and approval policy. This policy should require that management formally review and approve all expense transactions on a timely basis.
Finding 2024-006: Cash Management Program Title: Defense Nuclear Nonproliferation Research Assistance Listing Number: 81.113 Federal Agency: U.S. Department of Energy Direct Award Identifying Numbers: DE-NA003862, DE-NA004179, DE-NA0004177 Federal Award Year: Year ended September 30, 2024 Program Title: Export Control and Related Border Security Assistance Listing Number: 19.901 Federal Agency: U.S. Department of State Direct Award Identifying Number: SAQMIP23CA0153 Pass-Through Entity Name, Pass-Through Identifying Number: The Research Foundation for SUNY, University at Albany, 3-98939 Federal Award Year: Year ended September 30, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Compliance Finding Criteria: 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). Under 2 CFR § 200.305(b)(3), when using the reimbursement method, entities should request payment as soon as possible after the costs are incurred to minimize the time between expenditure and Federal reimbursement. Condition: PFI does not have documentation of the review and approval of Federal cash drawdown requests prior to submission. During testing, we noted that drawdowns totaling $219,376 for ALN 81.113 and $188,631 for ALN 19.901 were processed without evidence of supervisory review. Additionally, we noted that PFI submitted a late cash drawdown request for Federal expenditures of $74,111 under ALN 81.113 that occurred during prior years but were newly identified and reimbursed during the year under audit. Cause: PFI has not implemented a formal review process for cash drawdowns. Furthermore, PFI lacks written procedures to ensure timely submission of reimbursement requests. Effect or Potential Effect: Lack of review increases the risk of drawing excessive funds, noncompliance with cash management requirements, and potential misuse of Federal funds. Delayed drawdowns resulted in PFI using non-Federal funds for an extended period of time, which may have impacted cash flow and program operations. Questioned Costs: None. Context: 4 out of 4 drawdown requests selected for testing under ALN 81.113 and 3 out of 3 drawdown requests selected for testing under ALN 19.901 did not have documented supervisory review and approval. 1 of 4 drawdown requests tested for ALN 81.113 was submitted late for expenditures that had occurred in prior fiscal years. The samples are representative of the population. Repeat Finding: Not applicable Recommendation: It is recommended that PFI establish and document a formal review and approval process for all cash drawdown requests, including maintaining evidence of supervisory approval. Furthermore, we recommend that PFI implement procedures to ensure reimbursement requests are submitted promptly after costs are incurred, ideally within 30 days.
Finding 2024-007: Procurement Program Title: Defense Nuclear Nonproliferation Research Assistance Listing Number: 81.113 Federal Agency: U.S. Department of Energy Direct Award Identifying Numbers: DE-NA003862, DE-NA004179, DE-NA0004177 Federal Award Year: Year ended September 30, 2024 Program Title: Export Control and Related Border Security Assistance Listing Number: 19.901 Federal Agency: U.S. Department of State Direct Award Identifying Number: SAQMIP23CA0153 Pass-Through Entity Name, Pass-Through Identifying Number: The Research Foundation for SUNY, University at Albany, 3-98939 Federal Award Year: Year ended September 30, 2024 Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 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). Per CFR §200.318-§200.326, non-Federal entities must maintain written procurement procedures that comply with Federal standards, including thresholds, methods of procurement, and documentation requirements. Noncompetitive procurements can only be awarded in accordance with §200.320(c). According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or more of the following circumstances apply: 1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the micro-purchase threshold, 2. The item is available only from a single source; 3. The public exigency or emergency for the requirement will not permit a delay resulting from publicizing a competitive solicitation; 4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive procurement in response to a written request from the non-Federal entity; or 5. After solicitation of a number of sources, competition is determined inadequate. Condition: We noted that PFI’s procurement policy does not contain a micropurchase threshold and its threshold for simplified acquisitions is not accurately defined in accordance with the applicable Uniform Guidance requirements. During our testing over procurement, we noted several instances where PFI did not clearly document the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Furthermore, there were instances where review and approval over procurement was evidenced but the reviewer was not included in PFI’s procurement policy list of authorized approvers. Cause: PFI’s procurement policy was out of date and had not been updated to align with the current version of the Uniform Guidance. Effect or Potential Effect: An outdated procurement policy increases the risk of noncompliance with Federal requirements, improper procurement practices, and potential disallowance of costs charged to Federal awards. Questioned Costs: $31,120 of known questioned costs were identified for 2 procurements under ALN 81.113. $15,000 of known questioned costs were identified for ALN 19.901 along with $806 of likely questioned costs based on projecting the known questioned costs to the remaining population of procurement transactions. Context: 2 of 2 samples selected for testing under ALN 81.113 and 1 out of 3 samples selected for testing under 19.901 did not have adequate documentation for the rationale related to the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. For 2 out of 2 samples under ALN 81.113 and 2 out of 3 samples under ALN 19.901, PFI had evidence of review and approval, but the reviewer was not on PFI’s authorized list included in its procurement policy. The samples are representative of the populations. Repeat Finding: Not applicable. Recommendation: We recommend that PFI revise its procurement policy to fully comply with the requirements in the latest version of the Uniform Guidance. In particular, the revised policy should include a micropurchase threshold, an accurate simplified acquisition threshold, and update the authorized list of reviewers for procurement transactions.
Finding No.: 2024-006 Federal Agency: U.S. Department of Education AL Program: 84.027 Special Education Grants to States Area: Period of Performance Questioned Costs: $39,665 Criteria: In accordance with applicable period of performance (POP) requirements, a non-federal entity may charge only allowable costs incurred during a federal award’s period of performance. Unless the federal awarding agency authorizes an extension, a non-federal entity must liquidate all financial obligations incurred under the federal award not later than 120 calendar days after the end date of the period of performance as specified in the terms and conditions of the federal award or in the approved extension. Furthermore, 2 CFR 200.303(a) states that the recipient must establish, document, and maintain effective internal control over the Federal award 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. These internal controls should align with the 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 COSO. Conditions: Of sixty items, aggregating $384,666 of $3,198,523 of expenditures subjected to period of performance test, deficiencies were noted, as follows: 1. For 4 items or (7%), GDOE charged costs to a federal award after the period of performance ended and liquidated obligations of a federal award after the approved liquidation end date: Federal Award No. Purchase Order/ Invoice No. Invoice Date POP End Date Liquidation End Date Liquidation Date Expenditures Questioned Costs H027A210013 20232230 08/27/2024 09/30/2023 01/28/2024 08/01/2025 3,240 3,240 H027A220013 20233151 01/28/2025 09/30/2024 01/28/2025 Not yet paid 17,953 17,953 H027A220013 20233151 01/28/2025 09/30/2024 01/28/2025 Not yet paid 10,636 10,636 H027A220013 20240021 04/29/2025 09/30/2024 01/28/2025 Not yet paid 7,408 7,408 $39,237 $39,237 Finding No.: 2024-006, continued Federal Agency: U.S. Department of Education AL Program: 84.027 Special Education Grants to States Area: Period of Performance Questioned Costs: $39,665 Conditions, continued: 2. For 1 item or (2%), compliance with period of performance of expenditure (PO# 20241462) amounting to $428 could not be determined as supporting documents such as an invoice or canceled check was not made available for examination. 3. There is no review in place to ensure that liquidation of the obligation occur within the allowable time period. Cause: GDOE did not enforce monitoring controls over compliance with applicable period of performance requirements relating to charging of costs to a federal award within the period of performance. Also, GDOE’s internal control policies and procedures in place are not suitably designed to ensure that liquidation of the obligation occurs within the allowable time period. Effect: GDOE is in noncompliance with applicable period of performance requirements. The reportable questioned cost is $39,665. Identified as a Repeat Finding: 2023-009 Recommendation: Responsible personnel should enforce monitoring controls over compliance with applicable period of performance requirements. Prior to charging costs to a federal award or liquidating obligations incurred under a federal award, responsible personnel should verify that the period of performance, including the liquidation end date, has not expired. Views of Responsible Officials: The Division of Special Education is currently reviewing the details of the finding in order to provide an adequate response and corrective action plan.
Internal Control over Compliance Significant Deficiency Federal Grantor: U.S. Department of Health and Human Services Federal Program: Centers for Independent Living Assistance Listing Number: 93.432 Criteria: 2 CFR 200.303 (Uniform Guidance) – Internal Controls is the regulation that requires Federal entities receiving Federal awards to establish and maintain effective internal controls over those awards to ensure compliance with Federal statutes, regulations, and the award terms. These controls must include processes to monitor compliance, take prompt action on non-compliance, and safeguard sensitive information. Condition and Context: Internal controls designed relating to the major program’s direct and material compliance requirements were not operating effectively. Cause: Management was not following the Organization’s approved control activities for federal awards. Effect: Without effective internal controls, material non-compliance due to error or fraud could occur and not be detected. Questioned Costs: None. Context: We tested internal control over compliance for the direct and material compliance requirements of the Organization’s major program.Recommendation: We recommend management review and reinforce the Organization’s established control activities related to federal awards. This should include comprehensive training for staff involved in federal program administration, regular monitoring to ensure controls are consistently applied, and periodic internal audits to assess the effectiveness of compliance systems. We also recommend documenting all significant control activities and monitoring procedures, including review and approval, for future audit purposes. By strengthening adherence to approved control activities, the Organization will reduce the risk of potential non-compliance with federal requirements. Views of Responsible Official: Immediate Control Reinforcement and Staff Training - The Executive Director and the Program Manager have already started identifying specific areas of each contract and grant for federal awards. The Executive Director will call a meeting between all managers to go over each contract and grants together with information that has already been reviewed. It will be important to observe specific instances when controls were created, and documentation was not accurate. Staff will be trained regarding the agency budget, and each role and responsibility of their program to better understand how their service delivery affects organizational funding. Monthly monitoring of grant funding from all managers will be important for transparency and prudent decision making. All managers will receive frequent training to keep up with any changes or new processes that will impact federal funding. Monitoring and Periodic Internal Auditing - The Executive Director, Program Manager, and Finance manager will meet every month before the Finance Committee meeting to go over the progression of spending. The Executive Director and Finance Manager will keep record of all information that will be helpful for the next audit regarding federal grants. Written corrective action plans will be created for each area of noncompliance. Finance Manager will be responsible for maintaining accurate budget updates and will inform Executive Director of any updates and changes as soon as they happen to ensure full transparency and preparation. Failure to do so will result in disciplinary consequences. All information will be presented to the Board of Directors whether at the monthly Board meeting or at the request for a special meeting. Documentation and Formalization - The Executive Director will meet with the Finance Manager to understand what process is used for quality assurance and documentation the finance staff uses. Any improvements necessary will be implemented as soon as possible after evaluating all processes. An evaluation of the software used for tracking all grant funding will be done and any quality assurance improvements will be implemented as soon as possible. Federal grants compliance adherence will be included in performance reviews and documented.
2024-101: Reimbursement Requests were Not Formally Approved by the City Prior to Submission Assistance Listing Number: 97.036 Program Title: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Compliance Requirement: Special Tests and Provisions Pass-through Entity: Florida Division of Emergency Management Federal Grant/Contract Number and Grant Year Z0894 2019 Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 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 terms and conditions of the federal awards. Condition: The reimbursement requests to the Florida Division of Emergency Management were prepared by the City’s consultant and acknowledged as approved by them as well. In the two reimbursement requests selected for sampling, one of the requests was both submitted and acknowledged by the third-party administrator. This was not a statistically valid sample. Cause: The City implemented procedures to ensure they are the entity to provide the acknowledgement of approval on the Florida Division of Emergency Management FEMA website for reimbursement requests submitted by the third-party consultants however those processes were not followed by the third-party administrator and subsequently not corrected by the City. Effect: Reimbursement requests could include potential errors and cause the City to be out of compliance with the requirements of the grant Recommendation: The City should consistently be the entity to acknowledge and approve the submission of the request on the Florida Division of Emergency Management FEMA website. If it is not feasible for them to be on the website then email confirmation between the City and the consultant should be obtained which supports the review and approval of the submission by the City. Management Response: See attached Corrective Action Plan
2024-006: Preparation of Schedule of Expenditures of Federal Awards (SEFA) (repeat) Finding Type: Material Weakness in Internal Controls and Noncompliance (Reporting, Cash Management and Allowable Costs/Cost Principles) Federal Program: U.S. Department of Transportation – Airport Improvement Program (AL #20.106); all project numbers and U.S. Department of Treasury – Coronavirus State and Local Fiscal Recovery Funds (AL #21.027) Criteria: The Code of Federal Regulations (CFR) Section 200.303(b) requires non-Federal entities 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 terms and conditions of the Federal award. CFR Section 200.502(a) states that the determination of when a Federal award is expended should be based on when the activity related to the Federal award occurs. Generally, the activity pertains to events that require the non-Federal entity to comply with Federal statutes, regulations, and the terms and conditions of Federal awards, such as expenditure/expense transactions associated with grant awards. The County reports expenditures on the SEFA when the expenditure has been incurred, or on the accrual basis of accounting, in accordance with generally accepted accounting principles. CFR Section 200.510(b) requires the auditee to prepare a SEFA for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with CFR Section 200.502(a), as stated above, and must reconcile amounts reported in the SEFA to the amounts reported in the auditee’s financial statements. Condition: The SEFA was not appropriately reconciled to federal grant revenues and expenditures recorded in the financial statements. Changes were made to major program expenditures, as well as expenditures of other programs, during the closing process and during the completion of the single audit to properly report expenditures on the SEFA. Closing procedures should be in place to reconcile grant expenditures incurred at year-end, confirm the amount as eligible with the grantor, claim the grant revenues on a timely basis, reconcile the claim to the general ledger, and ensure the expenditures that will be claimed under federal awards are properly reported on the SEFA and audited financial statements prior to the start of the single audit. If expenditures reported on the SEFA are misstated, the County could fail to have a program appropriately identified as a major program and tested as a major program during the single audit. Failure to have a program audited during the single audit would result in noncompliance with Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Cause: Closing procedures were not in place and management did not effectively communicate with County departments responsible for administering federal awards to identify all federal grant related activity. Effect: The SEFA required material adjustments to include all federal expenditures prior to the single audit beginning, which resulted in a misstated preliminary SEFA and inefficiencies during the single audit. In addition, the lack of closing procedures resulted in audit delays which caused the 2022 through 2024 financial reporting process, including data collection form submission, to be untimely. Questioned Costs: No costs have been questioned as a result of this finding. Recommendation: We recommend that management meet with department heads throughout the year and during the closing process to identify all expenditures under federal awards. Training should be provided to all staff to make sure they are aware of the importance of accurately reconciling and claiming grant expenditures on a timely basis and providing the information to management for inclusion on the SEFA. Views of Responsible Officials: The County will work to improve closing processes and communications with various departments to ensure the SEFA is complete and accurate.
2024-007: Written Policies Required by the Uniform Guidance (repeat) Finding Type: Material Weakness in Internal Controls and Noncompliance (Reporting and Allowable Costs/Cost Principles) Federal Program: U.S. Department of Transportation – Airport Improvement Program (AL #20.106); all project numbers and U.S. Department of Treasury – Coronavirus State and Local Fiscal Recovery Funds (AL #21.027) Criteria: Delta County does not have written policies and procedures to implement the requirements of 2 CFR section 200 for the administration of federal awards. The Uniform Guidance requires a non-federal entity that has expended federal awards for a grant on or after December 26, 2014 to have written policies pertaining to: 1) advance payments and reimbursements; 2) determination of allowable costs; 3) compensation (personnel and benefits policies); 4) travel costs; and 5) procurement procedures. 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal controls over the federal awards that provide assurance that the entity is managing the federal awards in compliance with federal statutes, regulations, and the conditions of the federal award. Condition: The County does not have processes in place to conform to all of the requirements in the Uniform Guidance. Cause: The County has not reviewed and updated its policies and procedures for continued changes in grants and the Uniform Guidance. Certain departmental grants operate outside of the general County processes and internal control system and policies and procedures for these departments have not been maintained. Effect: As a result of this condition, the County did not fully comply with the Uniform Guidance. Questioned Costs: No costs have been questioned as a result of this finding. Recommendation: We recommend that the County adopt formal written policies covering these areas as soon as practical. Views of Responsible Officials: The County will work to update policies and procedures and to formalize responsibilities.
2024-001 – Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Information on Federal Program(s) - Department of Education Assistance Listing Number: 84.351 Assistance Listing Name: Arts in Education National Program Grant Award Number: S351A220007 Award Period: October 1, 2023 to September 30, 2024 Criteria or Specific Requirement – The Uniform Guidance in 2 CFR Section 200.303 requires that non-Federal entities receiving Federal awards (i.e., auditee management) establish and maintain internal control designed to reasonably ensure compliance with Federal statues, regulations, and the terms and conditions of the Federal award. In addition, per 2 CFR Section 200.403, “Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: (a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles. (b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. (c) Be consistent with policies and procedures that apply uniformly to both federally-financed and other activities of the non-Federal entity. (d) Be accorded consistent treatment. A cost may not be assigned to a Federal award as a direct cost if any other cost incurred for the same purpose in like circumstances has been allocated to the Federal award as an indirect cost. (e) Be determined in accordance with generally accepted accounting principles (GAAP). (f) Not be included as a cost or used to meet cost sharing or matching requirements of any other federally-financed program in either the current or a prior period. (g) Be adequately documented. (h) Cost must be incurred during the approved budget period. The Federal awarding agency is authorized, at its discretion, to waive prior written approvals to carry forward unobligated balances to subsequent budget periods pursuant to § 200.308(e)(3).” Condition – In evaluating the Center’s compliance with the requirements of Activities Allowed or Unallowed and Allowable Costs Cost Principles, our test work identified one instance out of a sample of sixty payroll transactions, totaling $66,904.92, in which an employee was not paid according to his (her) contract. For the one exception, the employee was underpaid a total of $0.24. Cause – The Center did not adhere to their internal process to ensure approved salary information was accurately applied. Effect or Potential Effect – Without adequate internal controls in place to ensure costs are properly verified and applied, the Center could inaccurately charge expenditures to the federal program. Questioned Costs – N/A Context – This is a condition based on testing of the Center’s compliance. Based on tested samples, we noted a total underpayment of $0.24. The prevalence of the finding is detailed in the condition section above. The samples were selected using a non-statistical method. Repeat Finding – This is a repeat finding from prior year. This was reported as finding 2023-001 in the 2023 report. Recommendation - We recommend management of the Center strengthen their internal process to ensure that employee salary information recorded in the payroll system is approved, supported by salary documentation in the personnel files, and accurately applied. Views of Responsible Officials – After performing a detailed analysis, the Center’s management identified that the likely net underpayment amounted to $1.32. The likely underpayment was determined by management through examination of the total salary charged to the federal program. The Center’s management agrees with the finding and will strengthen the internal process surrounding the activities allowed or unallowed and allowable costs and will ensure adequate documentation is in place and approved salary rates are consistently and properly applied. See the Center’s corrective action for more details.
2024-001 – Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Information on Federal Program(s) - Department of Education Assistance Listing Number: 84.351 Assistance Listing Name: Arts in Education National Program Grant Award Number: S351A220007 Award Period: October 1, 2023 to September 30, 2024 Criteria or Specific Requirement – The Uniform Guidance in 2 CFR Section 200.303 requires that non-Federal entities receiving Federal awards (i.e., auditee management) establish and maintain internal control designed to reasonably ensure compliance with Federal statues, regulations, and the terms and conditions of the Federal award. In addition, per 2 CFR Section 200.403, “Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: (a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles. (b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. (c) Be consistent with policies and procedures that apply uniformly to both federally-financed and other activities of the non-Federal entity. (d) Be accorded consistent treatment. A cost may not be assigned to a Federal award as a direct cost if any other cost incurred for the same purpose in like circumstances has been allocated to the Federal award as an indirect cost. (e) Be determined in accordance with generally accepted accounting principles (GAAP). (f) Not be included as a cost or used to meet cost sharing or matching requirements of any other federally-financed program in either the current or a prior period. (g) Be adequately documented. (h) Cost must be incurred during the approved budget period. The Federal awarding agency is authorized, at its discretion, to waive prior written approvals to carry forward unobligated balances to subsequent budget periods pursuant to § 200.308(e)(3).” Condition – In evaluating the Center’s compliance with the requirements of Activities Allowed or Unallowed and Allowable Costs Cost Principles, our test work identified one instance out of a sample of sixty payroll transactions, totaling $66,904.92, in which an employee was not paid according to his (her) contract. For the one exception, the employee was underpaid a total of $0.24. Cause – The Center did not adhere to their internal process to ensure approved salary information was accurately applied. Effect or Potential Effect – Without adequate internal controls in place to ensure costs are properly verified and applied, the Center could inaccurately charge expenditures to the federal program. Questioned Costs – N/A Context – This is a condition based on testing of the Center’s compliance. Based on tested samples, we noted a total underpayment of $0.24. The prevalence of the finding is detailed in the condition section above. The samples were selected using a non-statistical method. Repeat Finding – This is a repeat finding from prior year. This was reported as finding 2023-001 in the 2023 report. Recommendation - We recommend management of the Center strengthen their internal process to ensure that employee salary information recorded in the payroll system is approved, supported by salary documentation in the personnel files, and accurately applied. Views of Responsible Officials – After performing a detailed analysis, the Center’s management identified that the likely net underpayment amounted to $1.32. The likely underpayment was determined by management through examination of the total salary charged to the federal program. The Center’s management agrees with the finding and will strengthen the internal process surrounding the activities allowed or unallowed and allowable costs and will ensure adequate documentation is in place and approved salary rates are consistently and properly applied. See the Center’s corrective action for more details.
Federal Agency: U.S. Department of Education Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recurring: No Compliance Requirement: Special tests and Provisions - Enrollment Program Information: Student Financial Aid Cluster (ALN 84.007, 84.003, 84.063, 84.268) Criteria: CFR section 685.309 and 690.83(b)(2) requires Colleges to notify the NSLDS within 30 days of a change in student status or include the change in status in a response to an enrollment reporting roster within 60 days of the student’s date of determination of withdrawal. 2 CFR Section 200.303 requires entities receiving Federal awards establish and maintain internal controls deigned to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should include procedures in place to ensure accurate reporting of enrollment status changes. Condition: Out of 40 students sampled from the College’s roster files, 3 out of 40 did not have updated enrollment statuses reported to NSLDS. Cause: The financial aid office does not have an effective system in place to ensure all official student status changes are reported accurately. Effect: Failure to report status changes timely is noncompliance with Federal regulation and could result in loss of future funding. Questioned Cost: None Recommendations: The College should implement monitoring procedures which will promptly notify the financial aid office of any student status changes. A system of monitoring procedures and/or controls will ensure the College is reporting any status changes accurately. The College should implement a review process to ensure all status changes are addressed by the financial aid office. View of Responsible Officials: The College’s management will address the matter identified as described in the corrective action plan.
Federal Agency: U.S. Department of Education Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recurring: No Compliance Requirement: Special tests and Provisions - Enrollment Program Information: Student Financial Aid Cluster (ALN 84.007, 84.003, 84.063, 84.268) Criteria: CFR section 685.309 and 690.83(b)(2) requires Colleges to notify the NSLDS within 30 days of a change in student status or include the change in status in a response to an enrollment reporting roster within 60 days of the student’s date of determination of withdrawal. 2 CFR Section 200.303 requires entities receiving Federal awards establish and maintain internal controls deigned to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should include procedures in place to ensure accurate reporting of enrollment status changes. Condition: Out of 40 students sampled from the College’s roster files, 3 out of 40 did not have updated enrollment statuses reported to NSLDS. Cause: The financial aid office does not have an effective system in place to ensure all official student status changes are reported accurately. Effect: Failure to report status changes timely is noncompliance with Federal regulation and could result in loss of future funding. Questioned Cost: None Recommendations: The College should implement monitoring procedures which will promptly notify the financial aid office of any student status changes. A system of monitoring procedures and/or controls will ensure the College is reporting any status changes accurately. The College should implement a review process to ensure all status changes are addressed by the financial aid office. View of Responsible Officials: The College’s management will address the matter identified as described in the corrective action plan.
Federal Agency: U.S. Department of Education Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recurring: No Compliance Requirement: Special tests and Provisions - Enrollment Program Information: Student Financial Aid Cluster (ALN 84.007, 84.003, 84.063, 84.268) Criteria: CFR section 685.309 and 690.83(b)(2) requires Colleges to notify the NSLDS within 30 days of a change in student status or include the change in status in a response to an enrollment reporting roster within 60 days of the student’s date of determination of withdrawal. 2 CFR Section 200.303 requires entities receiving Federal awards establish and maintain internal controls deigned to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should include procedures in place to ensure accurate reporting of enrollment status changes. Condition: Out of 40 students sampled from the College’s roster files, 3 out of 40 did not have updated enrollment statuses reported to NSLDS. Cause: The financial aid office does not have an effective system in place to ensure all official student status changes are reported accurately. Effect: Failure to report status changes timely is noncompliance with Federal regulation and could result in loss of future funding. Questioned Cost: None Recommendations: The College should implement monitoring procedures which will promptly notify the financial aid office of any student status changes. A system of monitoring procedures and/or controls will ensure the College is reporting any status changes accurately. The College should implement a review process to ensure all status changes are addressed by the financial aid office. View of Responsible Officials: The College’s management will address the matter identified as described in the corrective action plan.
Federal Agency: U.S. Department of Education Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recurring: No Compliance Requirement: Special tests and Provisions - Enrollment Program Information: Student Financial Aid Cluster (ALN 84.007, 84.003, 84.063, 84.268) Criteria: CFR section 685.309 and 690.83(b)(2) requires Colleges to notify the NSLDS within 30 days of a change in student status or include the change in status in a response to an enrollment reporting roster within 60 days of the student’s date of determination of withdrawal. 2 CFR Section 200.303 requires entities receiving Federal awards establish and maintain internal controls deigned to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should include procedures in place to ensure accurate reporting of enrollment status changes. Condition: Out of 40 students sampled from the College’s roster files, 3 out of 40 did not have updated enrollment statuses reported to NSLDS. Cause: The financial aid office does not have an effective system in place to ensure all official student status changes are reported accurately. Effect: Failure to report status changes timely is noncompliance with Federal regulation and could result in loss of future funding. Questioned Cost: None Recommendations: The College should implement monitoring procedures which will promptly notify the financial aid office of any student status changes. A system of monitoring procedures and/or controls will ensure the College is reporting any status changes accurately. The College should implement a review process to ensure all status changes are addressed by the financial aid office. View of Responsible Officials: The College’s management will address the matter identified as described in the corrective action plan.
PROGRAM DESCRIPTION Reference Number: 2024-004 Proper review of payroll charges to grant funds ALN 84.425U & 84.425W COVID-19 Education Stabilization Fund Pass through identifying number: 21528001245902 Award Year: 2023-2024 Federal Agency: U.S. Department of Education Passed through State Department of Education Criteria: Non-federal entities are required to establish and maintain effective internal controls over compliance in accordance with 2 CFR 200.303(a) and 2 CFR 200.430(g) which requires that compensation charged to federal awards must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated, of which documentation must be incorporated into the official records of the entity. Condition Found: During our review of payroll charges that were funded through ESSER funds, it was noted that the District did not have adequate controls in place to monitor the payroll transactions charged to the program. Cause: Although the District implemented Skyward in the prior year, the District did not integrate the appropriate approvals into the system in a timely manner. In addition, turnover in the District Chief Financial Officer position caused difficulties in the District obtaining the proper approvals for journal entries. Effect: The District could fail to appropriately support expenditures charged to the program. Questioned Cost: $0 Recommendation: We recommend the District to implement appropriate approvals in the Skyward accounting system to provide for better oversight of transactions. Views of Responsible Officials: Management agrees with the findings. See corrective action plan beginning on page 114.
PROGRAM DESCRIPTION Reference Number: 2024-004 Proper review of payroll charges to grant funds ALN 84.425U & 84.425W COVID-19 Education Stabilization Fund Pass through identifying number: 21528001245902 Award Year: 2023-2024 Federal Agency: U.S. Department of Education Passed through State Department of Education Criteria: Non-federal entities are required to establish and maintain effective internal controls over compliance in accordance with 2 CFR 200.303(a) and 2 CFR 200.430(g) which requires that compensation charged to federal awards must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated, of which documentation must be incorporated into the official records of the entity. Condition Found: During our review of payroll charges that were funded through ESSER funds, it was noted that the District did not have adequate controls in place to monitor the payroll transactions charged to the program. Cause: Although the District implemented Skyward in the prior year, the District did not integrate the appropriate approvals into the system in a timely manner. In addition, turnover in the District Chief Financial Officer position caused difficulties in the District obtaining the proper approvals for journal entries. Effect: The District could fail to appropriately support expenditures charged to the program. Questioned Cost: $0 Recommendation: We recommend the District to implement appropriate approvals in the Skyward accounting system to provide for better oversight of transactions. Views of Responsible Officials: Management agrees with the findings. See corrective action plan beginning on page 114.
PROGRAM DESCRIPTION Reference Number: 2024-004 Proper review of payroll charges to grant funds ALN 84.425U & 84.425W COVID-19 Education Stabilization Fund Pass through identifying number: 21528001245902 Award Year: 2023-2024 Federal Agency: U.S. Department of Education Passed through State Department of Education Criteria: Non-federal entities are required to establish and maintain effective internal controls over compliance in accordance with 2 CFR 200.303(a) and 2 CFR 200.430(g) which requires that compensation charged to federal awards must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated, of which documentation must be incorporated into the official records of the entity. Condition Found: During our review of payroll charges that were funded through ESSER funds, it was noted that the District did not have adequate controls in place to monitor the payroll transactions charged to the program. Cause: Although the District implemented Skyward in the prior year, the District did not integrate the appropriate approvals into the system in a timely manner. In addition, turnover in the District Chief Financial Officer position caused difficulties in the District obtaining the proper approvals for journal entries. Effect: The District could fail to appropriately support expenditures charged to the program. Questioned Cost: $0 Recommendation: We recommend the District to implement appropriate approvals in the Skyward accounting system to provide for better oversight of transactions. Views of Responsible Officials: Management agrees with the findings. See corrective action plan beginning on page 114.
PROGRAM DESCRIPTION Reference Number: 2024-004 Proper review of payroll charges to grant funds ALN 84.425U & 84.425W COVID-19 Education Stabilization Fund Pass through identifying number: 21528001245902 Award Year: 2023-2024 Federal Agency: U.S. Department of Education Passed through State Department of Education Criteria: Non-federal entities are required to establish and maintain effective internal controls over compliance in accordance with 2 CFR 200.303(a) and 2 CFR 200.430(g) which requires that compensation charged to federal awards must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated, of which documentation must be incorporated into the official records of the entity. Condition Found: During our review of payroll charges that were funded through ESSER funds, it was noted that the District did not have adequate controls in place to monitor the payroll transactions charged to the program. Cause: Although the District implemented Skyward in the prior year, the District did not integrate the appropriate approvals into the system in a timely manner. In addition, turnover in the District Chief Financial Officer position caused difficulties in the District obtaining the proper approvals for journal entries. Effect: The District could fail to appropriately support expenditures charged to the program. Questioned Cost: $0 Recommendation: We recommend the District to implement appropriate approvals in the Skyward accounting system to provide for better oversight of transactions. Views of Responsible Officials: Management agrees with the findings. See corrective action plan beginning on page 114.
Federal Agency: U.S. Department of Education Federal Program Title: Student Financial Aid Cluster ALN Numbers: Multiple Award Period: September 1, 2023 through August 31, 2024 Type of Finding: • Significant Deficiency in Internal Control Over Compliance • Other Matters Criteria or Specific Requirement: The 2 CFR Section 200.303 require that nonfederal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal Statues, regulations, and the term and conditions of the federal awards. Condition: During our testing of Common Origination and Disbursement (COD), Return of Title IV Funds (R2T4) and National Student Loan Data System (NSLDS), we noted there was a review process implemented; however, there was no process in place to retain the review being performed as to provide evidence to ensure the controls are being performed effectively. Questioned Costs: None. Context: During our testing, it was noted the University does not have a process in place to ensure controls are being performed effectively. Cause: The University did not have a process in place to ensure controls implemented are being performed effectively Effect: There is no way to determine who was involved in the process should an error be present. Repeat Finding: No Recommendation: We recommend the University reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Views of Responsible Officials: There is no disagreement with the audit finding.
Federal Agency: U.S. Department of Education Federal Program Title: Student Financial Aid Cluster ALN Numbers: Multiple Award Period: September 1, 2023 through August 31, 2024 Type of Finding: • Significant Deficiency in Internal Control Over Compliance • Other Matters Criteria or Specific Requirement: The 2 CFR Section 200.303 require that nonfederal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal Statues, regulations, and the term and conditions of the federal awards. Condition: During our testing of Common Origination and Disbursement (COD), Return of Title IV Funds (R2T4) and National Student Loan Data System (NSLDS), we noted there was a review process implemented; however, there was no process in place to retain the review being performed as to provide evidence to ensure the controls are being performed effectively. Questioned Costs: None. Context: During our testing, it was noted the University does not have a process in place to ensure controls are being performed effectively. Cause: The University did not have a process in place to ensure controls implemented are being performed effectively Effect: There is no way to determine who was involved in the process should an error be present. Repeat Finding: No Recommendation: We recommend the University reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Views of Responsible Officials: There is no disagreement with the audit finding.
Federal Agency: U.S. Department of Education Federal Program Title: Student Financial Aid Cluster ALN Numbers: Multiple Award Period: September 1, 2023 through August 31, 2024 Type of Finding: • Significant Deficiency in Internal Control Over Compliance • Other Matters Criteria or Specific Requirement: The 2 CFR Section 200.303 require that nonfederal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal Statues, regulations, and the term and conditions of the federal awards. Condition: During our testing of Common Origination and Disbursement (COD), Return of Title IV Funds (R2T4) and National Student Loan Data System (NSLDS), we noted there was a review process implemented; however, there was no process in place to retain the review being performed as to provide evidence to ensure the controls are being performed effectively. Questioned Costs: None. Context: During our testing, it was noted the University does not have a process in place to ensure controls are being performed effectively. Cause: The University did not have a process in place to ensure controls implemented are being performed effectively Effect: There is no way to determine who was involved in the process should an error be present. Repeat Finding: No Recommendation: We recommend the University reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Views of Responsible Officials: There is no disagreement with the audit finding.
Federal Agency: U.S. Department of Education Federal Program Title: Student Financial Aid Cluster ALN Numbers: Multiple Award Period: September 1, 2023 through August 31, 2024 Type of Finding: • Significant Deficiency in Internal Control Over Compliance • Other Matters Criteria or Specific Requirement: The 2 CFR Section 200.303 require that nonfederal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal Statues, regulations, and the term and conditions of the federal awards. Condition: During our testing of Common Origination and Disbursement (COD), Return of Title IV Funds (R2T4) and National Student Loan Data System (NSLDS), we noted there was a review process implemented; however, there was no process in place to retain the review being performed as to provide evidence to ensure the controls are being performed effectively. Questioned Costs: None. Context: During our testing, it was noted the University does not have a process in place to ensure controls are being performed effectively. Cause: The University did not have a process in place to ensure controls implemented are being performed effectively Effect: There is no way to determine who was involved in the process should an error be present. Repeat Finding: No Recommendation: We recommend the University reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Views of Responsible Officials: There is no disagreement with the audit finding.
Federal Agency: U.S. Department of Education Federal Program Title: Student Financial Aid Cluster ALN Numbers: Multiple Award Period: September 1, 2023 through August 31, 2024 Type of Finding: • Significant Deficiency in Internal Control Over Compliance • Other Matters Criteria or Specific Requirement: The 2 CFR Section 200.303 require that nonfederal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal Statues, regulations, and the term and conditions of the federal awards. Condition: During our testing of Common Origination and Disbursement (COD), Return of Title IV Funds (R2T4) and National Student Loan Data System (NSLDS), we noted there was a review process implemented; however, there was no process in place to retain the review being performed as to provide evidence to ensure the controls are being performed effectively. Questioned Costs: None. Context: During our testing, it was noted the University does not have a process in place to ensure controls are being performed effectively. Cause: The University did not have a process in place to ensure controls implemented are being performed effectively Effect: There is no way to determine who was involved in the process should an error be present. Repeat Finding: No Recommendation: We recommend the University reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Views of Responsible Officials: There is no disagreement with the audit finding.
Compliance Requirement: 2 CFR 200.303 Internal Controls Name of Federal Agency: Corporation for National and Community Service Pass-through Agency: State of Louisiana/Volunteer Louisiana Questioned Costs: None. Condition: During our audit, we obtained an understanding and tested LDSC’s internal control for purposes of planning and performing our audit procedures. In obtaining our understanding and testing LDSC’s internal controls, we determined there were inadequate segregation of duties involving certain aspects of the financial reporting cycle. Criteria: 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).” Cause: Due to the size of LDSC’s administrative staff, certain duties are performed by the same individual, as follows: • Initiate and approve vendor invoices for payment, • Write checks or initiating electronic disbursements, • Review and approve payroll, including the approver’s payroll • Initiate and approve reimbursements to themselves as the agency head, • Access to check stock, check signing authority, and approval authorization. The following responsibilities over cash receipts are performed by the same individual: • Receive and open mail, • Prepare bank deposits and deposit monies received, • Invoices customers for services provided (host sites). Effect: There is not adequate segregation of duties. Recommendation: We recommend LDSC to continue its practice of involving members of the board and its contract accountant to be involved in the financial reporting process to the extent practical to mitigate the risks related to limited segregation of duties. Views of Responsible Officials: See views of responsible officials on page 27.
Compliance Requirement: 2 CFR 200.303 Internal Controls Name of Federal Agency: Corporation for National and Community Service Pass-through Agency: State of Louisiana/Volunteer Louisiana Questioned Costs: None. Condition: During our audit, we obtained an understanding and tested LDSC’s internal control for purposes of planning and performing our audit procedures. In obtaining our understanding and testing LDSC’s internal controls, we determined there were inadequate segregation of duties involving certain aspects of the financial reporting cycle. Criteria: 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).” Cause: Due to the size of LDSC’s administrative staff, certain duties are performed by the same individual, as follows: • Initiate and approve vendor invoices for payment, • Write checks or initiating electronic disbursements, • Review and approve payroll, including the approver’s payroll • Initiate and approve reimbursements to themselves as the agency head, • Access to check stock, check signing authority, and approval authorization. The following responsibilities over cash receipts are performed by the same individual: • Receive and open mail, • Prepare bank deposits and deposit monies received, • Invoices customers for services provided (host sites). Effect: There is not adequate segregation of duties. Recommendation: We recommend LDSC to continue its practice of involving members of the board and its contract accountant to be involved in the financial reporting process to the extent practical to mitigate the risks related to limited segregation of duties. Views of Responsible Officials: See views of responsible officials on page 27.
Assistance Listing Number, Federal Agency, and Program Name -93.233/93.837, U.S. Department of Health and Human Services, Research and Development Cluster 93.323, U.S. Department of Health and Human Services, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Federal Award Identification Number and Year - 93.233 - R01HL142116; 93.837 - U01HL146245 93.323 - 22680258J; 32680012K Pass-through Entity - 93.233 N/A (direct); 93.837 N/A (direct) 93.323 Illinois Department of Public Health (IDPH) Finding Type - Material weakness and material noncompliance with laws and regulations Repeat Finding - No Criteria - Per 2 CFR 200.303(a), nonfederal entities must establish and maintain effective internal controls over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with the guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Per 2 CFR 200.318(a), the nonfederal entity must have and use documented procedures, consistent with state, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a federal award or subaward. The nonfederal entity's documented procurement procedures must conform to the procurement standards identified in §§200.317 through 200.327. Per 2 CFR 200.318(i), the nonfederal 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. Per 2 CFR 200.324(a), the nonfederal entity must perform a cost or price analysis in connection with every procurement action in excess of the SAT, including contract modifications. The method and degree of analysis is dependent upon the facts surrounding the particular procurement situation; but, as a starting point, the nonfederal entity must make independent estimates before receiving bids or proposals. Condition - Controls were not sufficient to establish written policies and procedures surrounding procured contracts and to ensure that the history of procurement decisions was documented, as required by 2 CFR 200. Questioned Costs - Research and Development Cluster - unknown ELC - unknown Identification of How Questioned Costs Were Computed - N/A Context - Research and Development Cluster - For the four contracts tested, management did not maintain records sufficient to detail the history of procurement, rationale for the method of procurement, selection of the contract type, or basis of the contract price. Additionally, for the largest of the four contracts with activity of approximately $375,000, which is above the SAT established by FAR, management did not document its rationale for limiting competition, nor was management able to provide evidence that a cost-price analysis was performed. Finally, management has not formally documented an appropriate micropurchase or SAT threshold. ELC - For the three of the four contracts tested that were procured under noncompetitive means, management did not maintain records sufficient to detail the history of procurement, rationale for the method of procurement, selection of the contract type, or basis of the contract price. Further, for three out of four contracts tested under the Research and Development Cluster and all four contracts tested under ELC, management was unable to provide evidence that contractors were checked for suspension and debarment in advance of entering into a covered transaction. Because there was evidence that these contractors were not suspended or debarred, no questioned costs related to this noncompliance were identified. Cause and Effect - A lack of formal procurement policies and procedures, internally established procurement thresholds, or records in support of procurement decisions could result in material noncompliance with federal procurement standards. Recommendation - We recommend that management formalize procurement policies and procedures to demonstrate how the Institute will achieve compliance with standards identified in §§200.317 through 200.327. Additionally, we recommend management retain documented evidence that its policies and procedures were followed to ensure compliance with procurement standards. Views of Responsible Officials and Corrective Action Plan – Management agrees with the recommendation and will review the relevant guidance to ensure compliance. Necessary revisions will be made to the existing procurement policies and procedures in a timely manner to ensure that procurement decisions are documented, as required by 2 CFR Part 200.
Assistance Listing Number, Federal Agency, and Program Name -93.233/93.837, U.S. Department of Health and Human Services, Research and Development Cluster 93.323, U.S. Department of Health and Human Services, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Federal Award Identification Number and Year - 93.233 - R01HL142116; 93.837 - U01HL146245 93.323 - 22680258J; 32680012K Pass-through Entity - 93.233 N/A (direct); 93.837 N/A (direct) 93.323 Illinois Department of Public Health (IDPH) Finding Type - Material weakness and material noncompliance with laws and regulations Repeat Finding - No Criteria - Per 2 CFR 200.303(a), nonfederal entities must establish and maintain effective internal controls over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with the guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Per 2 CFR 200.318(a), the nonfederal entity must have and use documented procedures, consistent with state, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a federal award or subaward. The nonfederal entity's documented procurement procedures must conform to the procurement standards identified in §§200.317 through 200.327. Per 2 CFR 200.318(i), the nonfederal 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. Per 2 CFR 200.324(a), the nonfederal entity must perform a cost or price analysis in connection with every procurement action in excess of the SAT, including contract modifications. The method and degree of analysis is dependent upon the facts surrounding the particular procurement situation; but, as a starting point, the nonfederal entity must make independent estimates before receiving bids or proposals. Condition - Controls were not sufficient to establish written policies and procedures surrounding procured contracts and to ensure that the history of procurement decisions was documented, as required by 2 CFR 200. Questioned Costs - Research and Development Cluster - unknown ELC - unknown Identification of How Questioned Costs Were Computed - N/A Context - Research and Development Cluster - For the four contracts tested, management did not maintain records sufficient to detail the history of procurement, rationale for the method of procurement, selection of the contract type, or basis of the contract price. Additionally, for the largest of the four contracts with activity of approximately $375,000, which is above the SAT established by FAR, management did not document its rationale for limiting competition, nor was management able to provide evidence that a cost-price analysis was performed. Finally, management has not formally documented an appropriate micropurchase or SAT threshold. ELC - For the three of the four contracts tested that were procured under noncompetitive means, management did not maintain records sufficient to detail the history of procurement, rationale for the method of procurement, selection of the contract type, or basis of the contract price. Further, for three out of four contracts tested under the Research and Development Cluster and all four contracts tested under ELC, management was unable to provide evidence that contractors were checked for suspension and debarment in advance of entering into a covered transaction. Because there was evidence that these contractors were not suspended or debarred, no questioned costs related to this noncompliance were identified. Cause and Effect - A lack of formal procurement policies and procedures, internally established procurement thresholds, or records in support of procurement decisions could result in material noncompliance with federal procurement standards. Recommendation - We recommend that management formalize procurement policies and procedures to demonstrate how the Institute will achieve compliance with standards identified in §§200.317 through 200.327. Additionally, we recommend management retain documented evidence that its policies and procedures were followed to ensure compliance with procurement standards. Views of Responsible Officials and Corrective Action Plan – Management agrees with the recommendation and will review the relevant guidance to ensure compliance. Necessary revisions will be made to the existing procurement policies and procedures in a timely manner to ensure that procurement decisions are documented, as required by 2 CFR Part 200.
Assistance Listing Number, Federal Agency, and Program Name -93.233/93.837, U.S. Department of Health and Human Services, Research and Development Cluster 93.323, U.S. Department of Health and Human Services, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Federal Award Identification Number and Year - 93.233 - R01HL142116; 93.837 - U01HL146245 93.323 - 22680258J; 32680012K Pass-through Entity - 93.233 N/A (direct); 93.837 N/A (direct) 93.323 Illinois Department of Public Health (IDPH) Finding Type - Material weakness and material noncompliance with laws and regulations Repeat Finding - No Criteria - Per 2 CFR 200.303(a), nonfederal entities must establish and maintain effective internal controls over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with the guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Per 2 CFR 200.318(a), the nonfederal entity must have and use documented procedures, consistent with state, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a federal award or subaward. The nonfederal entity's documented procurement procedures must conform to the procurement standards identified in §§200.317 through 200.327. Per 2 CFR 200.318(i), the nonfederal 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. Per 2 CFR 200.324(a), the nonfederal entity must perform a cost or price analysis in connection with every procurement action in excess of the SAT, including contract modifications. The method and degree of analysis is dependent upon the facts surrounding the particular procurement situation; but, as a starting point, the nonfederal entity must make independent estimates before receiving bids or proposals. Condition - Controls were not sufficient to establish written policies and procedures surrounding procured contracts and to ensure that the history of procurement decisions was documented, as required by 2 CFR 200. Questioned Costs - Research and Development Cluster - unknown ELC - unknown Identification of How Questioned Costs Were Computed - N/A Context - Research and Development Cluster - For the four contracts tested, management did not maintain records sufficient to detail the history of procurement, rationale for the method of procurement, selection of the contract type, or basis of the contract price. Additionally, for the largest of the four contracts with activity of approximately $375,000, which is above the SAT established by FAR, management did not document its rationale for limiting competition, nor was management able to provide evidence that a cost-price analysis was performed. Finally, management has not formally documented an appropriate micropurchase or SAT threshold. ELC - For the three of the four contracts tested that were procured under noncompetitive means, management did not maintain records sufficient to detail the history of procurement, rationale for the method of procurement, selection of the contract type, or basis of the contract price. Further, for three out of four contracts tested under the Research and Development Cluster and all four contracts tested under ELC, management was unable to provide evidence that contractors were checked for suspension and debarment in advance of entering into a covered transaction. Because there was evidence that these contractors were not suspended or debarred, no questioned costs related to this noncompliance were identified. Cause and Effect - A lack of formal procurement policies and procedures, internally established procurement thresholds, or records in support of procurement decisions could result in material noncompliance with federal procurement standards. Recommendation - We recommend that management formalize procurement policies and procedures to demonstrate how the Institute will achieve compliance with standards identified in §§200.317 through 200.327. Additionally, we recommend management retain documented evidence that its policies and procedures were followed to ensure compliance with procurement standards. Views of Responsible Officials and Corrective Action Plan – Management agrees with the recommendation and will review the relevant guidance to ensure compliance. Necessary revisions will be made to the existing procurement policies and procedures in a timely manner to ensure that procurement decisions are documented, as required by 2 CFR Part 200.
Assistance Listing Number, Federal Agency, and Program Name -93.233/93.837, U.S. Department of Health and Human Services, Research and Development Cluster 93.323, U.S. Department of Health and Human Services, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Federal Award Identification Number and Year - 93.233 - R01HL142116; 93.837 - U01HL146245 93.323 - 22680258J; 32680012K Pass-through Entity - 93.233 N/A (direct); 93.837 N/A (direct) 93.323 Illinois Department of Public Health (IDPH) Finding Type - Material weakness and material noncompliance with laws and regulations Repeat Finding - No Criteria - Per 2 CFR 200.303(a), nonfederal entities must establish and maintain effective internal controls over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with the guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Per 2 CFR 200.318(a), the nonfederal entity must have and use documented procedures, consistent with state, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a federal award or subaward. The nonfederal entity's documented procurement procedures must conform to the procurement standards identified in §§200.317 through 200.327. Per 2 CFR 200.318(i), the nonfederal 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. Per 2 CFR 200.324(a), the nonfederal entity must perform a cost or price analysis in connection with every procurement action in excess of the SAT, including contract modifications. The method and degree of analysis is dependent upon the facts surrounding the particular procurement situation; but, as a starting point, the nonfederal entity must make independent estimates before receiving bids or proposals. Condition - Controls were not sufficient to establish written policies and procedures surrounding procured contracts and to ensure that the history of procurement decisions was documented, as required by 2 CFR 200. Questioned Costs - Research and Development Cluster - unknown ELC - unknown Identification of How Questioned Costs Were Computed - N/A Context - Research and Development Cluster - For the four contracts tested, management did not maintain records sufficient to detail the history of procurement, rationale for the method of procurement, selection of the contract type, or basis of the contract price. Additionally, for the largest of the four contracts with activity of approximately $375,000, which is above the SAT established by FAR, management did not document its rationale for limiting competition, nor was management able to provide evidence that a cost-price analysis was performed. Finally, management has not formally documented an appropriate micropurchase or SAT threshold. ELC - For the three of the four contracts tested that were procured under noncompetitive means, management did not maintain records sufficient to detail the history of procurement, rationale for the method of procurement, selection of the contract type, or basis of the contract price. Further, for three out of four contracts tested under the Research and Development Cluster and all four contracts tested under ELC, management was unable to provide evidence that contractors were checked for suspension and debarment in advance of entering into a covered transaction. Because there was evidence that these contractors were not suspended or debarred, no questioned costs related to this noncompliance were identified. Cause and Effect - A lack of formal procurement policies and procedures, internally established procurement thresholds, or records in support of procurement decisions could result in material noncompliance with federal procurement standards. Recommendation - We recommend that management formalize procurement policies and procedures to demonstrate how the Institute will achieve compliance with standards identified in §§200.317 through 200.327. Additionally, we recommend management retain documented evidence that its policies and procedures were followed to ensure compliance with procurement standards. Views of Responsible Officials and Corrective Action Plan – Management agrees with the recommendation and will review the relevant guidance to ensure compliance. Necessary revisions will be made to the existing procurement policies and procedures in a timely manner to ensure that procurement decisions are documented, as required by 2 CFR Part 200.