BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Head Start Cluster Federal Assistance Listing Number: 93.600 Federal Award Identification Number(s) and Year(s): 05CH010838-2022, 05HE001017-2021, 05CH010838-2023 Award Period: March 1, 2022 to February 28, 2023; April 1, 2021 to March 31, 2023; and March 1, 2023 to February 29, 2024 Type of Finding: Material Weakness in Internal Control over Major Federal Programs and Other Matters Criteria or Specific Requirement: Under 2 CFR section 200.303, a non-federal entity must establish and maintain effective internal controls over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Timely review and approval should be maintained to ensure accurate reports are submitted and that reports are also being submitted on time. Condition: The Organization does not have adequate internal controls in place to ensure required reports are approved by the appropriate personnel before being submitted and that reports are being timely submitted. Questioned Costs: N/A Context: For the three financial status reports and one special report selected for testing, all did not contain a formal documented review and approval. Also, the one special report selected for testing did not have timely submission. Cause: While management does have a separate individual assigned to review the required reports prepared by the Fiscal Director, that review is not formally documented. Effect: Potential for inaccurate information reported and untimely submission. Repeat Finding: This is not a repeat finding. Recommendation: We recommend that the assigned individual to review formally documents their review and approval of the reports with a signature before the required date to be submitted. We recommend implementing a process to ensure timely submission of all reports. Views of responsible officials and planned corrective actions: There is no disagreement with the finding. WCCA will implement a control policy for a documented review and approval of reports prior to submission as well as ensuring reports are filed timely.
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Head Start Cluster Federal Assistance Listing Number: 93.600 Federal Award Identification Number(s) and Year(s): 05CH010838-2022, 05HE001017-2021, 05CH010838-2023 Award Period: March 1, 2022 to February 28, 2023; April 1, 2021 to March 31, 2023; and March 1, 2023 to February 29, 2024 Type of Finding: Material Weakness in Internal Control over Major Federal Programs and Other Matters Criteria or Specific Requirement: Under 2 CFR section 200.303, a non-federal entity must establish and maintain effective internal controls over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Timely review and approval should be maintained to ensure accurate reports are submitted and that reports are also being submitted on time. Condition: The Organization does not have adequate internal controls in place to ensure required reports are approved by the appropriate personnel before being submitted and that reports are being timely submitted. Questioned Costs: N/A Context: For the three financial status reports and one special report selected for testing, all did not contain a formal documented review and approval. Also, the one special report selected for testing did not have timely submission. Cause: While management does have a separate individual assigned to review the required reports prepared by the Fiscal Director, that review is not formally documented. Effect: Potential for inaccurate information reported and untimely submission. Repeat Finding: This is not a repeat finding. Recommendation: We recommend that the assigned individual to review formally documents their review and approval of the reports with a signature before the required date to be submitted. We recommend implementing a process to ensure timely submission of all reports. Views of responsible officials and planned corrective actions: There is no disagreement with the finding. WCCA will implement a control policy for a documented review and approval of reports prior to submission as well as ensuring reports are filed timely.
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Head Start Cluster Federal Assistance Listing Number: 93.600 Federal Award Identification Number(s) and Year(s): 05CH010838-2022, 05HE001017-2021, 05CH010838-2023 Award Period: March 1, 2022 to February 28, 2023; April 1, 2021 to March 31, 2023; and March 1, 2023 to February 29, 2024 Type of Finding: Material Weakness in Internal Control over Major Federal Programs and Other Matters Criteria or Specific Requirement: Under 2 CFR section 200.303, a non-federal entity must establish and maintain effective internal controls over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Timely review and approval should be maintained to ensure accurate reports are submitted and that reports are also being submitted on time. Condition: The Organization does not have adequate internal controls in place to ensure required reports are approved by the appropriate personnel before being submitted and that reports are being timely submitted. Questioned Costs: N/A Context: For the three financial status reports and one special report selected for testing, all did not contain a formal documented review and approval. Also, the one special report selected for testing did not have timely submission. Cause: While management does have a separate individual assigned to review the required reports prepared by the Fiscal Director, that review is not formally documented. Effect: Potential for inaccurate information reported and untimely submission. Repeat Finding: This is not a repeat finding. Recommendation: We recommend that the assigned individual to review formally documents their review and approval of the reports with a signature before the required date to be submitted. We recommend implementing a process to ensure timely submission of all reports. Views of responsible officials and planned corrective actions: There is no disagreement with the finding. WCCA will implement a control policy for a documented review and approval of reports prior to submission as well as ensuring reports are filed timely.
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Head Start Cluster Federal Assistance Listing Number: 93.600 Federal Award Identification Number(s) and Year(s): 05CH010838-2022, 05HE001017-2021, 05CH010838-2023 Award Period: March 1, 2022 to February 28, 2023; April 1, 2021 to March 31, 2023; and March 1, 2023 to February 29, 2024 Type of Finding: Material Weakness in Internal Control over Major Federal Programs and Other Matters Criteria or Specific Requirement: Under 2 CFR section 200.303, a non-federal entity must establish and maintain effective internal controls over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Timely review and approval should be maintained to ensure accurate reports are submitted and that reports are also being submitted on time. Condition: The Organization does not have adequate internal controls in place to ensure required reports are approved by the appropriate personnel before being submitted and that reports are being timely submitted. Questioned Costs: N/A Context: For the three financial status reports and one special report selected for testing, all did not contain a formal documented review and approval. Also, the one special report selected for testing did not have timely submission. Cause: While management does have a separate individual assigned to review the required reports prepared by the Fiscal Director, that review is not formally documented. Effect: Potential for inaccurate information reported and untimely submission. Repeat Finding: This is not a repeat finding. Recommendation: We recommend that the assigned individual to review formally documents their review and approval of the reports with a signature before the required date to be submitted. We recommend implementing a process to ensure timely submission of all reports. Views of responsible officials and planned corrective actions: There is no disagreement with the finding. WCCA will implement a control policy for a documented review and approval of reports prior to submission as well as ensuring reports are filed timely.
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Head Start Cluster Federal Assistance Listing Number: 93.600 Federal Award Identification Number(s) and Year(s): 05CH010838-2022, 05HE001017-2021, 05CH010838-2023 Award Period: March 1, 2022 to February 28, 2023; April 1, 2021 to March 31, 2023; and March 1, 2023 to February 29, 2024 Type of Finding: Material Weakness in Internal Control over Major Federal Programs and Other Matters Criteria or Specific Requirement: Under 2 CFR section 200.303, a non-federal entity must establish and maintain effective internal controls over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Timely review and approval should be maintained to ensure accurate reports are submitted and that reports are also being submitted on time. Condition: The Organization does not have adequate internal controls in place to ensure required reports are approved by the appropriate personnel before being submitted and that reports are being timely submitted. Questioned Costs: N/A Context: For the three financial status reports and one special report selected for testing, all did not contain a formal documented review and approval. Also, the one special report selected for testing did not have timely submission. Cause: While management does have a separate individual assigned to review the required reports prepared by the Fiscal Director, that review is not formally documented. Effect: Potential for inaccurate information reported and untimely submission. Repeat Finding: This is not a repeat finding. Recommendation: We recommend that the assigned individual to review formally documents their review and approval of the reports with a signature before the required date to be submitted. We recommend implementing a process to ensure timely submission of all reports. Views of responsible officials and planned corrective actions: There is no disagreement with the finding. WCCA will implement a control policy for a documented review and approval of reports prior to submission as well as ensuring reports are filed timely.
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Head Start Cluster Federal Assistance Listing Number: 93.600 Federal Award Identification Number(s) and Year(s): 05CH010838-2022, 05HE001017-2021, 05CH010838-2023 Award Period: March 1, 2022 to February 28, 2023; April 1, 2021 to March 31, 2023; and March 1, 2023 to February 29, 2024 Type of Finding: Material Weakness in Internal Control over Major Federal Programs and Other Matters Criteria or Specific Requirement: Under 2 CFR section 200.303, a non-federal entity must establish and maintain effective internal controls over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Timely review and approval should be maintained to ensure accurate reports are submitted and that reports are also being submitted on time. Condition: The Organization does not have adequate internal controls in place to ensure required reports are approved by the appropriate personnel before being submitted and that reports are being timely submitted. Questioned Costs: N/A Context: For the three financial status reports and one special report selected for testing, all did not contain a formal documented review and approval. Also, the one special report selected for testing did not have timely submission. Cause: While management does have a separate individual assigned to review the required reports prepared by the Fiscal Director, that review is not formally documented. Effect: Potential for inaccurate information reported and untimely submission. Repeat Finding: This is not a repeat finding. Recommendation: We recommend that the assigned individual to review formally documents their review and approval of the reports with a signature before the required date to be submitted. We recommend implementing a process to ensure timely submission of all reports. Views of responsible officials and planned corrective actions: There is no disagreement with the finding. WCCA will implement a control policy for a documented review and approval of reports prior to submission as well as ensuring reports are filed timely.
Finding 2023-006 – CASH MANAGEMENT Type: Significant Deficiency in Internal Control. Program: ALN 93.493 Congressional Directives Criteria: Pursuant to 2 CFR 200.303, recipients must, “Establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient or subrecipient is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 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: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and approvals. Cause: This condition was caused by an insufficient internal control process for review and approval of cash requests. Effect: Cash requests submitted prior to review and approval are at risk of reporting incorrect information. Questioned Cost: None. Context: Although amounts listed in the cash requests were supported by the books and records, the requests did not contain evidence of approvals. Recommendation: We recommend that the CMHSP review their internal controls and make necessary changes to ensure that cash requests are reviewed and approved prior to submission. Management’s Resp: We are in agreement with this finding.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
Assistance Listing Number, Federal Agency, and Program Name - ALN 14.218, U.S. Department of Housing and Urban Development, Entitlement Grants Cluster (CDBG), Community Development Block Grants/Entitlement Grants Federal Award Identification Number and Year - All grants listed on SEFA Pass through Entity - Not applicable Finding Type - Material weakness Repeat Finding - No Criteria - Per 24 CFR Section 570.603, grantees must adhere to the labor standards applicable to non volunteer labor per 42 USC 53110 when rehabilitating residential property that contains no fewer than eight units, which includes ensuring prevailing wage rates are being used. Additionally, per 2 CFR Section 200.303, grantees must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government, issued by the Comptroller General of the United States, or the Internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition - The County did not have controls in place, during the year under audit, to ensure that the required certified payrolls were received and reviewed by the County. Questioned Costs - None Identification of How Questioned Costs Were Computed - Not applicable Context - The County has a process in place to receive and review weekly payroll certifications from contractors and subcontractors. However, there is not a control in place to ensure that all weekly payroll certifications have been received and reviewed. Cause and Effect - The County did not have controls in place ensure that the required certified payrolls were received and reviewed. For the sample selected for testing, the County was still in compliance with the applicable laws and regulations. Recommendation - We recommend that the County implement a control to ensure that the required certified payrolls from contractors and subcontractors are received and reviewed timely. Views of Responsible Officials and Corrective Action Plan A process will be put into place to ensure certified payrolls are received and reviewed by two staff employees.
AL Numbers: 93.575, 93.568 Name of Federal Program or Cluster: Child Care and Development Block Grant – CCDF Cluster and COVID-19 CCDF Cluster, Low-Income Home Energy Assistance Program (LIHEAP) and COVID-19 LIHEAP Award Number: 21PANDCCDF, 22PANDCCDD, 23PANDCCDD, 23PANDLIEA, 23PANDLIEE, 23 PANDLIEI Award Year: 2021, 2022, 2023 Criteria – In accordance with the Tribe’s grant award requirements and the Uniform Guidance 2 CFR 200.303, the Tribe must have internal controls in place for documenting and verifying eligibility to ensure compliance with federal requirements. Condition and context – We noted the following for each program: ALN 93.575 – Of the 158 provider payments made by the CCDF Cluster program during fiscal year 2023, we used a random sample selection methodology to select and test 32 files for eligibility. We noted 4 provider files did not contain proof of CPR certification, which is a required certification for all providers. Additionally, the Tribe’s CCDF program distributed American Rescue Plan Act (ARPA) Stabilization assistance payments to eligible providers. Of the 168 provider payments made using ARPA funds during fiscal year 2023, we used a random sample selection methodology to select and test 10 files for eligibility. We noted 2 provider files that were not in compliance with grant requirements. One file contained a background check that did not meet the grant’s criteria, and one file lacked sufficient evidence that childcare services were provided. ALN 93.568 – Of the 1004 LIHEAP participants during fiscal year 2023, we used a random sample selection methodology to select and test 60 files. We noted there was no documentation provided for 1 file. For 58 of the 59 files reviewed, we noted the same individual that made the eligibility determination also reviewed the file for accuracy without evidence of review by another individual. Of the 59 provider files reviewed, 17 were not in compliance with the eligibility requirements of the program, this included 8 files with incomplete documentation on income verification and 9 files with incomplete documentation on verification of household size. Cause – Inadequate internal controls over eligibility requirements may have led to this finding. Questioned costs – For the CCDF Cluster program, the known questioned costs identified were $4,985. For the LIHEAP Program, we were unable to determine questioned costs due to lack of sufficient information. Effect – It is possible that individuals not eligible to receive services may have received services. Repeat finding – This is a repeat finding and was reported in the prior year as findings 2022-002 and 2022-003. Recommendation – These programs should reexamine processes and controls over participant eligibility and implement a supervisory review process to establish strong internal controls over compliance. Views of responsible officials and planned corrective actions – ALN 93.575 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 (Provider files): In July 2025, the Program hired a Compliance Specialist to review provider files for compliance. In addition, the Program hired an employee to assist with the demanding workload. ALN 93.568 (participant files): the identified items of non-compliance were a direct result of program personnel turnover, including the Director. The Director position was vacant for the entire fiscal year. The Program is now fully staffed and working on ensuring that all intake items are clearly documented/retained in the participant files.
AL Numbers: 93.441 Name of Federal Program or Cluster: Indian Self-Determination – Indian Health Services (IHS) and COVID-19 IHS Award Number: HHS-I-241-2021-0002 Award Year: 2023 Criteria – In accordance with the Tribe’s grant award requirements and the Uniform Guidance 2 CFR 200.303, the Tribe must have internal controls in place for documenting and verifying eligibility to ensure compliance with federal requirements. Condition and context – Of the 65 participants in the Tribe’s treatment program during fiscal year 2023, we used a random sample selection methodology to select and test 8 files for eligibility. We noted 4 participant files were missing the program’s eligibility intake form, which documents the participant’s eligibility. Of the 4 files, we noted one file was missing proof of Tribal enrollment. Subsequent to our testing, the program was able to provide evidence of eligibility for each file tested. Cause – Turnover and vacancies in the program may have contributed to insufficient internal controls over eligibility. Questioned costs – As a control finding, there are no questioned costs applicable to this finding. Effect – It is possible that individuals not eligible to receive services may have received services. Repeat finding – This is not a repeat finding for this program. Recommendation – The program should reexamine processes and controls over participant eligibility and implement a supervisory review process to establish strong internal controls over compliance. Views of responsible officials and planned corrective actions – ALN 93.441 (participant eligibility): The Program was able to locate the missing eligibility documents which were subsequently provided to the auditor. The Program will ensure that such documentation is maintained in participant files in the future.
AL Numbers: 93.441 Name of Federal Program or Cluster: Indian Self-Determination – Indian Health Services (IHS) and COVID-19 IHS Award Number: HHS-I-241-2021-0002 Award Year: 2023 Criteria – In accordance with the Tribe’s grant award requirements and the Uniform Guidance 2 CFR 200.303, the Tribe must have internal controls in place for documenting and verifying eligibility to ensure compliance with federal requirements. Condition and context – Of the 65 participants in the Tribe’s treatment program during fiscal year 2023, we used a random sample selection methodology to select and test 8 files for eligibility. We noted 4 participant files were missing the program’s eligibility intake form, which documents the participant’s eligibility. Of the 4 files, we noted one file was missing proof of Tribal enrollment. Subsequent to our testing, the program was able to provide evidence of eligibility for each file tested. Cause – Turnover and vacancies in the program may have contributed to insufficient internal controls over eligibility. Questioned costs – As a control finding, there are no questioned costs applicable to this finding. Effect – It is possible that individuals not eligible to receive services may have received services. Repeat finding – This is not a repeat finding for this program. Recommendation – The program should reexamine processes and controls over participant eligibility and implement a supervisory review process to establish strong internal controls over compliance. Views of responsible officials and planned corrective actions – ALN 93.441 (participant eligibility): The Program was able to locate the missing eligibility documents which were subsequently provided to the auditor. The Program will ensure that such documentation is maintained in participant files in the future.
AL Numbers: 93.575, 93.568 Name of Federal Program or Cluster: Child Care and Development Block Grant – CCDF Cluster and COVID-19 CCDF Cluster, Low-Income Home Energy Assistance Program (LIHEAP) and COVID-19 LIHEAP Award Number: 21PANDCCDF, 22PANDCCDD, 23PANDCCDD, 23PANDLIEA, 23PANDLIEE, 23 PANDLIEI Award Year: 2021, 2022, 2023 Criteria – In accordance with the Tribe’s grant award requirements and the Uniform Guidance 2 CFR 200.303, the Tribe must have internal controls in place for documenting and verifying eligibility to ensure compliance with federal requirements. Condition and context – We noted the following for each program: ALN 93.575 – Of the 158 provider payments made by the CCDF Cluster program during fiscal year 2023, we used a random sample selection methodology to select and test 32 files for eligibility. We noted 4 provider files did not contain proof of CPR certification, which is a required certification for all providers. Additionally, the Tribe’s CCDF program distributed American Rescue Plan Act (ARPA) Stabilization assistance payments to eligible providers. Of the 168 provider payments made using ARPA funds during fiscal year 2023, we used a random sample selection methodology to select and test 10 files for eligibility. We noted 2 provider files that were not in compliance with grant requirements. One file contained a background check that did not meet the grant’s criteria, and one file lacked sufficient evidence that childcare services were provided. ALN 93.568 – Of the 1004 LIHEAP participants during fiscal year 2023, we used a random sample selection methodology to select and test 60 files. We noted there was no documentation provided for 1 file. For 58 of the 59 files reviewed, we noted the same individual that made the eligibility determination also reviewed the file for accuracy without evidence of review by another individual. Of the 59 provider files reviewed, 17 were not in compliance with the eligibility requirements of the program, this included 8 files with incomplete documentation on income verification and 9 files with incomplete documentation on verification of household size. Cause – Inadequate internal controls over eligibility requirements may have led to this finding. Questioned costs – For the CCDF Cluster program, the known questioned costs identified were $4,985. For the LIHEAP Program, we were unable to determine questioned costs due to lack of sufficient information. Effect – It is possible that individuals not eligible to receive services may have received services. Repeat finding – This is a repeat finding and was reported in the prior year as findings 2022-002 and 2022-003. Recommendation – These programs should reexamine processes and controls over participant eligibility and implement a supervisory review process to establish strong internal controls over compliance. Views of responsible officials and planned corrective actions – ALN 93.575 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 (Provider files): In July 2025, the Program hired a Compliance Specialist to review provider files for compliance. In addition, the Program hired an employee to assist with the demanding workload. ALN 93.568 (participant files): the identified items of non-compliance were a direct result of program personnel turnover, including the Director. The Director position was vacant for the entire fiscal year. The Program is now fully staffed and working on ensuring that all intake items are clearly documented/retained in the participant files.
AL Numbers: 93.575, 93.568 Name of Federal Program or Cluster: Child Care and Development Block Grant – CCDF Cluster and COVID-19 CCDF Cluster, Low-Income Home Energy Assistance Program (LIHEAP) and COVID-19 LIHEAP Award Number: 21PANDCCDF, 22PANDCCDD, 23PANDCCDD, 23PANDLIEA, 23PANDLIEE, 23 PANDLIEI Award Year: 2021, 2022, 2023 Criteria – In accordance with the Tribe’s grant award requirements and the Uniform Guidance 2 CFR 200.303, the Tribe must have internal controls in place for documenting and verifying eligibility to ensure compliance with federal requirements. Condition and context – We noted the following for each program: ALN 93.575 – Of the 158 provider payments made by the CCDF Cluster program during fiscal year 2023, we used a random sample selection methodology to select and test 32 files for eligibility. We noted 4 provider files did not contain proof of CPR certification, which is a required certification for all providers. Additionally, the Tribe’s CCDF program distributed American Rescue Plan Act (ARPA) Stabilization assistance payments to eligible providers. Of the 168 provider payments made using ARPA funds during fiscal year 2023, we used a random sample selection methodology to select and test 10 files for eligibility. We noted 2 provider files that were not in compliance with grant requirements. One file contained a background check that did not meet the grant’s criteria, and one file lacked sufficient evidence that childcare services were provided. ALN 93.568 – Of the 1004 LIHEAP participants during fiscal year 2023, we used a random sample selection methodology to select and test 60 files. We noted there was no documentation provided for 1 file. For 58 of the 59 files reviewed, we noted the same individual that made the eligibility determination also reviewed the file for accuracy without evidence of review by another individual. Of the 59 provider files reviewed, 17 were not in compliance with the eligibility requirements of the program, this included 8 files with incomplete documentation on income verification and 9 files with incomplete documentation on verification of household size. Cause – Inadequate internal controls over eligibility requirements may have led to this finding. Questioned costs – For the CCDF Cluster program, the known questioned costs identified were $4,985. For the LIHEAP Program, we were unable to determine questioned costs due to lack of sufficient information. Effect – It is possible that individuals not eligible to receive services may have received services. Repeat finding – This is a repeat finding and was reported in the prior year as findings 2022-002 and 2022-003. Recommendation – These programs should reexamine processes and controls over participant eligibility and implement a supervisory review process to establish strong internal controls over compliance. Views of responsible officials and planned corrective actions – ALN 93.575 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 (Provider files): In July 2025, the Program hired a Compliance Specialist to review provider files for compliance. In addition, the Program hired an employee to assist with the demanding workload. ALN 93.568 (participant files): the identified items of non-compliance were a direct result of program personnel turnover, including the Director. The Director position was vacant for the entire fiscal year. The Program is now fully staffed and working on ensuring that all intake items are clearly documented/retained in the participant files.
Condition: Texas Guaranteed Student Loan Corporation d/b/a Trellis Company (Trellis) as a guarantor works with borrowers who qualify for the teacher loan forgiveness program. Quarterly, Trellis will perform a quality review of five applications to verify the applicant was eligible for forgiveness. During fiscal year 2023, the quarterly review process was not completed from October through August. In addition, Trellis did not have a compensating control in place to monitor the completeness and accuracy of the teacher loan forgiveness process. When brought to the attention of management, Trellis performed the quarterly reviews for fiscal year 2023 in arrears prior to yearend. To verify remediation efforts, two quarters were sampled with no exceptions noted. Criteria or Requirement: 2 CFR 200.303 requires non-Federal entities receiving Federal awards 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. Effective internal controls should include procedures to ensure teacher loan forgiveness applications are processed correctly. Cause: Trellis opted to not perform the quarterly quality review process over teacher loan forgiveness claims as the volume of loans has continued to decline over the last few years, there were no errors noted in prior quarterly reviews, and the personnel performing the processes remained consistent. Possible Asserted Effect: Trellis could have approved a teacher loan forgiveness application that was not eligible. Repeat Finding: A similar finding was not reported in the prior year audit. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Recommendation: Trellis should reinstitute the quality control process. Views of Trellis Officials: Trellis agrees with this recommendation. Trellis reinstituted in arrears for fiscal year 2023 and is currently performing the quality reviews as described above for fiscal year 2023.
Total Unused Lost Revenues Reporting Federal program: U.S. Department of Health and Human Services – ALN 93.498, COVID-19—Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution. Criteria: 2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal award. Specific criteria are established by the U.S. Department of Health and Human Services (HHS) with respect to allowable cost and reporting requirements for this program, including: - Funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. - Entities may elect to calculate and report lost revenue using one of three options. For entities electing to report lost revenues using Option i, quarterly actual patient care revenues are to be reported. Condition: In preparing the Reporting Period 4 and 5 General Distribution submission report to Health Resources & Services Administration (HRSA), the Corporation did not reduce the Unused Lost Revenues included within the ARP Distribution submission report from the Unused Lost Revenues in the General Distribution report in the Current Reporting Period. This resulted in the Total Unused Lost Revenues in the Reporting Period 4 and 5 General Distribution submission reports to be overstated by $723,754. Context: The Corporation reported Total Unused Lost Revenues in the Reporting Period 4 and 5 General Distribution submission reports of $42,297,586 and $42,276,693. Had the correct amounts of Total Unused Lost Revenues in the Reporting Period 4 and 5 General Distribution submission reports been reported, the Total Unused Lost Revenues would have been $723,754 less. The Total Unused Lost Revenues would still have exceeded PRF amounts received. Cause: In preparing the Reporting Period 4 and 5 General Distribution submission report to Health Resources & Services Administration (HRSA), the Corporation did not reduce the Unused Lost Revenues included within the ARP Distribution submission report from the Unused Lost Revenues in the General Distribution report in the Current Reporting Period. This resulted in the Total Unused Lost Revenues in the Reporting Period 4 and 5 General Distribution submission reports to be overstated by $723,754. Review processes were performed before the reports were submitted, but these reviews were not effective in detecting and correcting the errors before report submission. Effect: The Total Unused Lost Revenues in the Reporting Period 4 and 5 General Distribution submission reports were overstated by $723,754. Questioned costs: None Repeat finding: No Recommendation: We recommend that internal controls be strengthened related to review of the quarterly lost revenue calculations and reporting in the PRF reporting portal. We suggest these reviews include review of documentation supporting input included in the report. View of responsible officials of the auditee: Management agrees with the finding, has prepared an assessment of the root cause of this significant deficiency, and has developed a corrective action plan.
Information on the Federal Program: Assistance Listing Number 10.565—Commodity Supplemental Food Program, U.S. Department of Agriculture. Pass-Through Entities and Award Numbers: Minnesota Department of Health, award number 204642. Compliance Requirement: Allowable Costs. Type of Finding: Significant deficiency in internal control over compliance. Criteria: 2 CFR 200.303 of Subpart D, "Post Federal Award Requirements Standards for Financial and Program Management," of the Uniform Guidance requires a nonfederal entity to establish and maintain effective internal control over the federal award that provides reasonable assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award, including Activities Allowed or Unallowed, Allowable Costs and Cost Principles. Condition: Controls were not operating to ensure that CSFP box sign out signatures were properly reviewed and tracked against reported totals. Cause: One monthly signature log for a CSFP distribution site had fewer signatures on their box sign out sheet than were reported on the signature log cover sheet. These should never be different, as the log cover sheet should be a representation of the number of signatures in the sign out sheet. The site representative responsible for ensuring these amounts agree did not perform the designed control. Effect or Potential Effect: Unallowable costs or activities could be charged to the grant. Questioned Costs: None Context: The number of boxes distributed reported on the summary signature log did not agree to the supporting signature detail. Repeat Finding: No Recommendation: We recommend a separate review of signature log cover sheets be documented by an agent independent of the distribution site. Views of Responsible Officials: Agree and controls have been implemented.
Information on the Federal Program: Assistance Listing Number 10.565—Commodity Supplemental Food Program, U.S. Department of Agriculture. Pass-Through Entities and Award Numbers: Minnesota Department of Health, award number 204642. Compliance Requirement: Eligibility. Type of Finding: Significant deficiency in internal control over compliance. Criteria: 2 CFR 200.303 of Subpart D, "Post Federal Award Requirements Standards for Financial and Program Management," of the Uniform Guidance requires a nonfederal entity to establish and maintain effective internal control over the federal award that provides reasonable assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award, including Eligibility. Condition: Controls were not operating effectively over CSFP eligibility. Cause: Some signed enrollment forms for CSFP participants detailing eligibility status were not available upon request. The signatures present on these forms indicate the performance of the review control being performed by Second Harvest Heartland personnel. They should confirm all the information included on the form to be correct. Effect or Potential Effect: An ineligible individual could receive a CSFP box. Questioned Costs: None Context: Signed enrollment forms were not available for two of forty participants selected. Repeat Finding: No Recommendation: We recommend that Second Harvest Heartland digitalize their CSFP enrollment forms for convenient access and so that every form is reviewed for signatures during their upload. Views of Responsible Officials: Agree.
Department of Health and Human Services Temporary Assistance for Needy Families, 93.558 Reporting Significant Deficiency in Internal Control over Compliance Grant Award Number: Affects all grant awards under assistance listing 93.558 on the Consolidated Schedule of Expenditures of Federal Awards Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: There was no evidence of review and approval prior to submission of the six programmatic reports selected for testing. Cause: Goodwill-Easter Seals Minnesota has a review process in place but was not formally documented. Effect: Failure to perform an independent review of reporting could result in a reasonable possibility that Goodwill-Easter Seals Minnesota would not detect errors in the normal course of performing duties and correct them in a timely manner. Questioned Costs: None reported. Context/Sampling: Six programmatic reporting submissions out of eighteen total reports were selected for testing the program. Repeat Finding from Prior Year: No Recommendation: We recommend that management develop a formal documented review over reporting and that documentation is retained to support compliance with program requirements. Views of Responsible Officials: Management agrees with this finding.
Department of Health and Human Services Temporary Assistance for Needy Families, 93.558 Reporting Significant Deficiency in Internal Control over Compliance Grant Award Number: Affects all grant awards under assistance listing 93.558 on the Consolidated Schedule of Expenditures of Federal Awards Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: There was no evidence of review and approval prior to submission of the six programmatic reports selected for testing. Cause: Goodwill-Easter Seals Minnesota has a review process in place but was not formally documented. Effect: Failure to perform an independent review of reporting could result in a reasonable possibility that Goodwill-Easter Seals Minnesota would not detect errors in the normal course of performing duties and correct them in a timely manner. Questioned Costs: None reported. Context/Sampling: Six programmatic reporting submissions out of eighteen total reports were selected for testing the program. Repeat Finding from Prior Year: No Recommendation: We recommend that management develop a formal documented review over reporting and that documentation is retained to support compliance with program requirements. Views of Responsible Officials: Management agrees with this finding.
Department of Health and Human Services Temporary Assistance for Needy Families, 93.558 Reporting Significant Deficiency in Internal Control over Compliance Grant Award Number: Affects all grant awards under assistance listing 93.558 on the Consolidated Schedule of Expenditures of Federal Awards Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: There was no evidence of review and approval prior to submission of the six programmatic reports selected for testing. Cause: Goodwill-Easter Seals Minnesota has a review process in place but was not formally documented. Effect: Failure to perform an independent review of reporting could result in a reasonable possibility that Goodwill-Easter Seals Minnesota would not detect errors in the normal course of performing duties and correct them in a timely manner. Questioned Costs: None reported. Context/Sampling: Six programmatic reporting submissions out of eighteen total reports were selected for testing the program. Repeat Finding from Prior Year: No Recommendation: We recommend that management develop a formal documented review over reporting and that documentation is retained to support compliance with program requirements. Views of Responsible Officials: Management agrees with this finding.
Department of Health and Human Services Temporary Assistance for Needy Families, 93.558 Reporting Significant Deficiency in Internal Control over Compliance Grant Award Number: Affects all grant awards under assistance listing 93.558 on the Consolidated Schedule of Expenditures of Federal Awards Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: There was no evidence of review and approval prior to submission of the six programmatic reports selected for testing. Cause: Goodwill-Easter Seals Minnesota has a review process in place but was not formally documented. Effect: Failure to perform an independent review of reporting could result in a reasonable possibility that Goodwill-Easter Seals Minnesota would not detect errors in the normal course of performing duties and correct them in a timely manner. Questioned Costs: None reported. Context/Sampling: Six programmatic reporting submissions out of eighteen total reports were selected for testing the program. Repeat Finding from Prior Year: No Recommendation: We recommend that management develop a formal documented review over reporting and that documentation is retained to support compliance with program requirements. Views of Responsible Officials: Management agrees with this finding.
Department of Health and Human Services Temporary Assistance for Needy Families, 93.558 Reporting Significant Deficiency in Internal Control over Compliance Grant Award Number: Affects all grant awards under assistance listing 93.558 on the Consolidated Schedule of Expenditures of Federal Awards Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: There was no evidence of review and approval prior to submission of the six programmatic reports selected for testing. Cause: Goodwill-Easter Seals Minnesota has a review process in place but was not formally documented. Effect: Failure to perform an independent review of reporting could result in a reasonable possibility that Goodwill-Easter Seals Minnesota would not detect errors in the normal course of performing duties and correct them in a timely manner. Questioned Costs: None reported. Context/Sampling: Six programmatic reporting submissions out of eighteen total reports were selected for testing the program. Repeat Finding from Prior Year: No Recommendation: We recommend that management develop a formal documented review over reporting and that documentation is retained to support compliance with program requirements. Views of Responsible Officials: Management agrees with this finding.
Department of Health and Human Services Temporary Assistance for Needy Families, 93.558 Reporting Significant Deficiency in Internal Control over Compliance Grant Award Number: Affects all grant awards under assistance listing 93.558 on the Consolidated Schedule of Expenditures of Federal Awards Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: There was no evidence of review and approval prior to submission of the six programmatic reports selected for testing. Cause: Goodwill-Easter Seals Minnesota has a review process in place but was not formally documented. Effect: Failure to perform an independent review of reporting could result in a reasonable possibility that Goodwill-Easter Seals Minnesota would not detect errors in the normal course of performing duties and correct them in a timely manner. Questioned Costs: None reported. Context/Sampling: Six programmatic reporting submissions out of eighteen total reports were selected for testing the program. Repeat Finding from Prior Year: No Recommendation: We recommend that management develop a formal documented review over reporting and that documentation is retained to support compliance with program requirements. Views of Responsible Officials: Management agrees with this finding.
Department of Health and Human Services Temporary Assistance for Needy Families, 93.558 Reporting Significant Deficiency in Internal Control over Compliance Grant Award Number: Affects all grant awards under assistance listing 93.558 on the Consolidated Schedule of Expenditures of Federal Awards Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: There was no evidence of review and approval prior to submission of the six programmatic reports selected for testing. Cause: Goodwill-Easter Seals Minnesota has a review process in place but was not formally documented. Effect: Failure to perform an independent review of reporting could result in a reasonable possibility that Goodwill-Easter Seals Minnesota would not detect errors in the normal course of performing duties and correct them in a timely manner. Questioned Costs: None reported. Context/Sampling: Six programmatic reporting submissions out of eighteen total reports were selected for testing the program. Repeat Finding from Prior Year: No Recommendation: We recommend that management develop a formal documented review over reporting and that documentation is retained to support compliance with program requirements. Views of Responsible Officials: Management agrees with this finding.
Department of Health and Human Services Temporary Assistance for Needy Families, 93.558 Reporting Significant Deficiency in Internal Control over Compliance Grant Award Number: Affects all grant awards under assistance listing 93.558 on the Consolidated Schedule of Expenditures of Federal Awards Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: There was no evidence of review and approval prior to submission of the six programmatic reports selected for testing. Cause: Goodwill-Easter Seals Minnesota has a review process in place but was not formally documented. Effect: Failure to perform an independent review of reporting could result in a reasonable possibility that Goodwill-Easter Seals Minnesota would not detect errors in the normal course of performing duties and correct them in a timely manner. Questioned Costs: None reported. Context/Sampling: Six programmatic reporting submissions out of eighteen total reports were selected for testing the program. Repeat Finding from Prior Year: No Recommendation: We recommend that management develop a formal documented review over reporting and that documentation is retained to support compliance with program requirements. Views of Responsible Officials: Management agrees with this finding.
Finding No: 2023-001 Activities Allowed or Unallowed/Allowable Costs Federal Agency: U.S. Department of Health and Human Services Assistance Listing Number: 93.498 Program: COVID -19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Year: January 1, 2020 through December 31, 2022 (a) Criteria or Requirement The specific requirements for activities allowed or unallowed are unique to each federal program and are found in the federal statutes, regulations, and the terms and conditions of the federal award pertaining to the program. This program allows expenditures to prevent, prepare for, and respond to coronavirus and COVID-19, domestically or internationally, for necessary expenses to reimburse, through grants or other mechanisms, eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus. Per 2 CFR 200.303, a non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. (b) Condition Found, Including Perspective During our test work, we selected a sample of 60 non-payroll disbursements made during the fiscal year 2023 reporting period. We noted eight instances totaling $1,717 in which expenditures were approved for payment based on vendor invoices which included inaccurate calculations. In addition, we noted three instances of duplicate expenditures totaling $38,971 being transferred and charged to the program. Lastly, the University was unable to provide supporting documentation and evidence of the effective operation of the management review control for one of the 60 disbursements sampled totaling $803. (c) Possible Cause The University has a management review process to review invoices and related documentation before payments are disbursed. The University management review control that was in place did not operate effectively to prevent duplicate charges, inaccurate amounts and charges that lacked supporting documentation from being submitted for reimbursement by the federal agency. (d) Questioned Cost Duplicate expenditures totaling $38,971 and payment of inaccurate vendor invoices totaling $1,717. (e) Effect Federal funds were expended for duplicated or inaccurate amounts and supporting documentation and evidence of the effective operation of management review controls were not consistently maintained in accordance with Federal requirements. (f) Statistical Validity The sample was not intended to be, and was not, a statistically valid sample. (g) Repeat Finding in the Prior Year This finding also occurred in the prior year listed as Finding No. 2022-001. (h) Recommendation We recommend that the University strengthen controls over the management review process to prevent duplicate and inaccurate amounts from being charged to Federal programs and to enhance the retention of supporting documentation and evidence of management review and approval. (i) View of Responsible Officials Management concurs with the finding. While appropriate controls exist relative to management review and recalculation of expenditures, opportunities exist to retrain staff and further enhance controls related to procedures for submission, review, and approval of contract labor invoices. Specific instructions to recalculate each contract employees’ timesheet(s) and agree the totals to the related invoice prior to approval were distributed and outlined for department managers, accountants, and accounts payable staff. In addition, the process for reviewing and approving grant expenditures has since been enhanced subsequent to manager turnover during the fiscal year. Specifically, employees responsible for processing grant transfer documentation will ensure documents contain management approval(s), grants and contracts accounting approval, and appropriate documentation prior to keying and uploading documentation into the general ledger. The new practice will help compensate for employee turnover as documentation of historical review will be available to successors.