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.
Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the Organization is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Organization's special reports submitted to the Department of Health and Human Services were not reviewed and approved by a separate individual outside of the preparer. Questioned Costs: Unknown Context: Key line items were tested on the Period 4 special reports submitted to the Department of Health and Human Services. 2 reports were tested, which both lacked appropriate approval. Cause: The Organization did not have an internal control process in place to ensure review and approval of the reports being submitted to the Department of Health and Human Services (HHS). Effect: There is a possibility that the reports may not be accurately completed. Repeat Finding: Yes Recommendation: We recommend that management implement a control process which includes approval of required reports to be submitted to the federal agency.
2023 – 007 Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: Varying project and budget periods: 2/1/22 – 1/31/23, 2/1/23 – 1/31/24, 4/1/21 – 3/31/23 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: 2 CFR 200.303(a) states 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 conditions of the federal award. Condition: In our audit testing around payroll expenditures, the Organization was not able to provide supporting documentation of the internal control process occurring where supervisors review and approve employee timesheets with each payroll. Questioned costs: None. Context: The Organization changed its payroll system during the year, and historic timesheet data, including documentation of approval on timesheets, was not retained in the transition. Therefore in our testing of 38 payroll transactions, we were able to get support for the underlying expenses to support an eligible grant expenditure, but not able to obtain support of the internal control occurring of supervisor approval of time. Cause: Payroll system transition resulted in loss of historic documentation on time sheets and supervisor approval. Effect: Without retained documentation, the Organization is not able to support the existence of internal controls in place. Recommendation: We recommend in the future the Organization retain documentation of key control processes occurring for a reasonable retention period to be able to support control activities around grant compliance and financial reporting. View of responsible officials: No disagreement with the finding. Management will retain timesheet documentation moving forward to support control process in place.
2023 – 008 Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: Varying project and budget periods: 2/1/22 – 1/31/23, 2/1/23 – 1/31/24, 4/1/21 – 3/31/23 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: 2 CFR 200.303(a) states 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 conditions of the federal award. Condition: The Organization did not have sufficient internal control process or review in place over required reporting for federal programs. There was no documentation retained of review occurring before submission of reports. Errors were identified in key line items tested in the UDS report filed for 2022 during the fiscal year 2023. Questioned costs: None. Context: While the Organization has historically had a review process over required federal program reporting, there was no documentation of that review occurring for the reports tested, including FFR reports and UDS report for the community health center grants. For the UDS report, due to an error in supporting schedules, amounts reported in Table 9E, lines 1g and 1q were overstated. There was turnover in key finance positions at the Organization, where historical segregation of duties between preparer and reviewer was not always possible. Cause: Turnover in personnel at the Organization likely led to lapses in review processes that had been in place historically. The lack of detailed review likely resulted in the errors identified in UDS reporting. Effect: Without sufficient review processes in place, there is greater risk of noncompliance or errors in required reporting under federal programs. In the case of the UDS reporting, certain line items were misreported due to errors in supporting spreadsheets. Repeat Finding: The finding is a repeat of finding in the immediately prior year. Prior year finding number was 2022-006. Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/approval occurrence. View of responsible officials: No disagreement with the finding. Management will implement a formal review process for reporting and retain documentation of review. This has been incorporated in subsequent reporting years.
2023 – 007 Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: Varying project and budget periods: 2/1/22 – 1/31/23, 2/1/23 – 1/31/24, 4/1/21 – 3/31/23 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: 2 CFR 200.303(a) states 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 conditions of the federal award. Condition: In our audit testing around payroll expenditures, the Organization was not able to provide supporting documentation of the internal control process occurring where supervisors review and approve employee timesheets with each payroll. Questioned costs: None. Context: The Organization changed its payroll system during the year, and historic timesheet data, including documentation of approval on timesheets, was not retained in the transition. Therefore in our testing of 38 payroll transactions, we were able to get support for the underlying expenses to support an eligible grant expenditure, but not able to obtain support of the internal control occurring of supervisor approval of time. Cause: Payroll system transition resulted in loss of historic documentation on time sheets and supervisor approval. Effect: Without retained documentation, the Organization is not able to support the existence of internal controls in place. Recommendation: We recommend in the future the Organization retain documentation of key control processes occurring for a reasonable retention period to be able to support control activities around grant compliance and financial reporting. View of responsible officials: No disagreement with the finding. Management will retain timesheet documentation moving forward to support control process in place.
2023 – 008 Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: Varying project and budget periods: 2/1/22 – 1/31/23, 2/1/23 – 1/31/24, 4/1/21 – 3/31/23 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: 2 CFR 200.303(a) states 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 conditions of the federal award. Condition: The Organization did not have sufficient internal control process or review in place over required reporting for federal programs. There was no documentation retained of review occurring before submission of reports. Errors were identified in key line items tested in the UDS report filed for 2022 during the fiscal year 2023. Questioned costs: None. Context: While the Organization has historically had a review process over required federal program reporting, there was no documentation of that review occurring for the reports tested, including FFR reports and UDS report for the community health center grants. For the UDS report, due to an error in supporting schedules, amounts reported in Table 9E, lines 1g and 1q were overstated. There was turnover in key finance positions at the Organization, where historical segregation of duties between preparer and reviewer was not always possible. Cause: Turnover in personnel at the Organization likely led to lapses in review processes that had been in place historically. The lack of detailed review likely resulted in the errors identified in UDS reporting. Effect: Without sufficient review processes in place, there is greater risk of noncompliance or errors in required reporting under federal programs. In the case of the UDS reporting, certain line items were misreported due to errors in supporting spreadsheets. Repeat Finding: The finding is a repeat of finding in the immediately prior year. Prior year finding number was 2022-006. Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/approval occurrence. View of responsible officials: No disagreement with the finding. Management will implement a formal review process for reporting and retain documentation of review. This has been incorporated in subsequent reporting years.
2023 – 007 Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: Varying project and budget periods: 2/1/22 – 1/31/23, 2/1/23 – 1/31/24, 4/1/21 – 3/31/23 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: 2 CFR 200.303(a) states 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 conditions of the federal award. Condition: In our audit testing around payroll expenditures, the Organization was not able to provide supporting documentation of the internal control process occurring where supervisors review and approve employee timesheets with each payroll. Questioned costs: None. Context: The Organization changed its payroll system during the year, and historic timesheet data, including documentation of approval on timesheets, was not retained in the transition. Therefore in our testing of 38 payroll transactions, we were able to get support for the underlying expenses to support an eligible grant expenditure, but not able to obtain support of the internal control occurring of supervisor approval of time. Cause: Payroll system transition resulted in loss of historic documentation on time sheets and supervisor approval. Effect: Without retained documentation, the Organization is not able to support the existence of internal controls in place. Recommendation: We recommend in the future the Organization retain documentation of key control processes occurring for a reasonable retention period to be able to support control activities around grant compliance and financial reporting. View of responsible officials: No disagreement with the finding. Management will retain timesheet documentation moving forward to support control process in place.
2023 – 008 Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: Varying project and budget periods: 2/1/22 – 1/31/23, 2/1/23 – 1/31/24, 4/1/21 – 3/31/23 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: 2 CFR 200.303(a) states 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 conditions of the federal award. Condition: The Organization did not have sufficient internal control process or review in place over required reporting for federal programs. There was no documentation retained of review occurring before submission of reports. Errors were identified in key line items tested in the UDS report filed for 2022 during the fiscal year 2023. Questioned costs: None. Context: While the Organization has historically had a review process over required federal program reporting, there was no documentation of that review occurring for the reports tested, including FFR reports and UDS report for the community health center grants. For the UDS report, due to an error in supporting schedules, amounts reported in Table 9E, lines 1g and 1q were overstated. There was turnover in key finance positions at the Organization, where historical segregation of duties between preparer and reviewer was not always possible. Cause: Turnover in personnel at the Organization likely led to lapses in review processes that had been in place historically. The lack of detailed review likely resulted in the errors identified in UDS reporting. Effect: Without sufficient review processes in place, there is greater risk of noncompliance or errors in required reporting under federal programs. In the case of the UDS reporting, certain line items were misreported due to errors in supporting spreadsheets. Repeat Finding: The finding is a repeat of finding in the immediately prior year. Prior year finding number was 2022-006. Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/approval occurrence. View of responsible officials: No disagreement with the finding. Management will implement a formal review process for reporting and retain documentation of review. This has been incorporated in subsequent reporting years.
2023 – 007 Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: Varying project and budget periods: 2/1/22 – 1/31/23, 2/1/23 – 1/31/24, 4/1/21 – 3/31/23 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: 2 CFR 200.303(a) states 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 conditions of the federal award. Condition: In our audit testing around payroll expenditures, the Organization was not able to provide supporting documentation of the internal control process occurring where supervisors review and approve employee timesheets with each payroll. Questioned costs: None. Context: The Organization changed its payroll system during the year, and historic timesheet data, including documentation of approval on timesheets, was not retained in the transition. Therefore in our testing of 38 payroll transactions, we were able to get support for the underlying expenses to support an eligible grant expenditure, but not able to obtain support of the internal control occurring of supervisor approval of time. Cause: Payroll system transition resulted in loss of historic documentation on time sheets and supervisor approval. Effect: Without retained documentation, the Organization is not able to support the existence of internal controls in place. Recommendation: We recommend in the future the Organization retain documentation of key control processes occurring for a reasonable retention period to be able to support control activities around grant compliance and financial reporting. View of responsible officials: No disagreement with the finding. Management will retain timesheet documentation moving forward to support control process in place.
2023 – 008 Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: Varying project and budget periods: 2/1/22 – 1/31/23, 2/1/23 – 1/31/24, 4/1/21 – 3/31/23 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: 2 CFR 200.303(a) states 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 conditions of the federal award. Condition: The Organization did not have sufficient internal control process or review in place over required reporting for federal programs. There was no documentation retained of review occurring before submission of reports. Errors were identified in key line items tested in the UDS report filed for 2022 during the fiscal year 2023. Questioned costs: None. Context: While the Organization has historically had a review process over required federal program reporting, there was no documentation of that review occurring for the reports tested, including FFR reports and UDS report for the community health center grants. For the UDS report, due to an error in supporting schedules, amounts reported in Table 9E, lines 1g and 1q were overstated. There was turnover in key finance positions at the Organization, where historical segregation of duties between preparer and reviewer was not always possible. Cause: Turnover in personnel at the Organization likely led to lapses in review processes that had been in place historically. The lack of detailed review likely resulted in the errors identified in UDS reporting. Effect: Without sufficient review processes in place, there is greater risk of noncompliance or errors in required reporting under federal programs. In the case of the UDS reporting, certain line items were misreported due to errors in supporting spreadsheets. Repeat Finding: The finding is a repeat of finding in the immediately prior year. Prior year finding number was 2022-006. Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/approval occurrence. View of responsible officials: No disagreement with the finding. Management will implement a formal review process for reporting and retain documentation of review. This has been incorporated in subsequent reporting years.
Item 2023-001 Special Tests and Provisions – Wage Rate Requirements Education Stabilization Fund (ESF) ALN# 84.425 U.S. Department of Education Passed through the State Department of Education Grant period – Year ended September 30, 2023 (84.425U) (84.425D) Criteria – Grantees should have controls in place to ensure that contractors and subcontractors are notified of the requirement to pay prevailing wage rates to all laborers and mechanics employed on construction contracts in excess of $2,000 financed by federal assistance funds and to submit weekly certified payrolls for each week in which contract work is performed. 2 CFR 200.303 requires the non_x0002_Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in accordance with all applicable statutes, regulations, and the terms and conditions of the Federal award.” 2 CFR 200.326 and 29 CFR Part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction (DOL Regulations) require the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls). Condition – There is a systemic lack of controls in place to ensure that contractors and subcontractors were notified of the requirements to comply with the wage rate requirements and provided timely certified payrolls throughout the construction projects. Cause – A clause describing the wage rate requirements was not added to the construction contracts. There was a lack of sufficient controls over the communication of this requirement to ensure the accuracy and completeness of the certified payrolls being provided to the Board. Effect – Lack of notification of the wage rate requirements to the contractors and subcontractors could lead to disallowed costs. We noted that payments to contractors did not have supporting documentation of certified payrolls. However, our audit disclosed no instances of unallowable costs. Questioned Costs – $316,382. Recommendation – We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. Management’s Response – The Board will strengthen the controls in place to provide assurance that proper prevailing wage rate clauses are added to construction contracts and certified payrolls are received from each week in which construction work is performed.
Item 2023-002 – Equipment and Real Property Management Education Stabilization Fund (ESF) ALN# 84.425 U.S. Department of Education Passed through the State Department of Education Grant period – Year ended September 30, 2023 (84.425U) (84.425D) Criteria – Grantees should have controls in place to ensure that all capital equipment or improvements to land, building, or equipment that were purchased with grant funds received prior approval prior to encumbrance of the expenditure. 2 CFR 200.303 requires the non-Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in accordance with all applicable statutes, regulations, and the terms and conditions of the Federal award.” 2 CFR 200.313 and 2 CFR 200.439 requires that the following rules of allow ability must apply to equipment and other capital expenditures “Capital expenditures for special purpose equipment are allowable as direct costs, provided that items with a unit cost of $5,000 or more have the prior written approval of the Federal awarding agency or pass-through entity.” 2 CFR 200.439(d)(1) requires that property records must be maintained for equipment acquired under a federal award that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), 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. A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. Condition – There is a systemic lack of controls in place to ensure that prior approval for capital expenditures for equipment acquisition or improvements to land, buildings, or equipment was obtained prior to incurring the expenditure. Additionally, controls were not in place to ensure that a physical inventory was taken at least once every two years. Cause – Certain capital equipment and improvements to building expenditures were not included in the approved budget to grantor. There was a lack of sufficient controls over the review of capital expenditures to ensure that they were included in the approved budget and that a physical inventory observation was made. Effect – Lack of approval over equipment and capital improvements could lead to disallowed costs. We noted that certain equipment and improvement projects were not included in approved budget for ESSER Funds. Failure to perform a physical inventory observation results in noncompliance with the grant agreement and could result in a misappropriation of assets. Questioned Costs – $57,438. Recommendation – We recommend the strengthening of controls to ensure that proper approval is received prior to the acquisition of improvements to land, building or equipment and that a physical inventory observation is conducted at least once every two years to ensure compliance with grant agreement. Management’s Response – The Board will strengthen the controls in place to provide assurance that proper approval is obtained from grantor agency prior to the purchase of equipment and real property and that a physical inventory observation is conducted at least once every two years.
Item 2023-003 – Activities Allowed or Unallowed/Allowable Costs/Cost Principles Education Stabilization Fund (ESF) ALN# 84.425 U.S. Department of Education Passed through the State Department of Education Grant period – Year ended September 30, 2023 (84.425U) (84.425D) Criteria – Grantees should have controls in place to ensure that grant monies are for allowable costs and allowable activities. 2 CFR 200.303 requires the non-Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non_x0002_Federal entity is managing the Federal award in accordance with all applicable statutes, regulations, and the terms and conditions of the Federal award.” Condition – In testing a statistically valid sample of 37 items, 7 did not show prior approval. There is a systemic lack of controls in place to ensure that prior approval for allowable costs/activities was obtained prior to incurring the expenditure. Cause – Certain cost charged against the grant for allowable cost/activities did not contain approval from the Superintendent as required. There was a lack of sufficient controls over the review of expenditures to ensure that they received proper approval prior to payment. Effect – Lack of approval over expenditures could lead to disallowed costs. Questioned Costs – N/A Recommendation – We recommend the strengthening of controls to ensure that proper approval is received prior to the encumbrance of an expenditure. Management’s Response – The Board will strengthen the controls in place to provide assurance that proper approval is obtained from required personnel prior to the encumbrance of an expenditure.
Finding 2023-02 - Activities Allowed or Unallowed Significant Deficiency in Internal Controls over Compliance Identification of the federal program(s): Assistance Listings program titles and numbers: 93.591 Family Violence Prevention and Services Act 14.228 Community Block Development Grant (CBDG-CV) Federal award identification number: 93.591: Ohio Domestic Violence Network (2021-CM-004-479CM), Ohio Office of Criminal Justice Services (2021-SA-RCC-459SA, 2021-AR-003-459AR, 2021-CM-003-459CM, 2023-VP-003-4194) 14.228: Ohio Department of Development (B-D-22-1AE-4) Name of the federal agencies: 93.591 Department of Health and Human Services 14.228 Department of Housing and Urban Development Name of the applicable pass-through entities: 93.591: Ohio Domestic Violence Network, Office of Criminal Justice Services 14.228: Ohio Department of Development Criteria or specific requirement (including statutory, regulatory, or other citation): The 2 CFR section 200.303 of the Uniform Guidance requires that non-federal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Condition: During the audit, it was noted that 48 out of 50 non-payroll charges for both programs lacked invoice approvals, as approvals were not required for the actual transactions. Instead, approvals are only obtained during the submission of budgets and related modifications. Cause: Failure to adhere to their established process led to the absence of approvals for the actual transactions. Effect or potential effect: Without adequate internal controls to ensure that all charges to the federal program are properly reviewed for allowability, SAOP could be noncompliant with the allowability requirement and might request funds for unallowed costs. Questioned costs: None Context: There are no invoice approvals for non-payroll charges in both programs Identification as a repeat finding, if applicable: Not applicable Recommendation: We recommend that SAOP secure approvals for charges related to the federal programs. Views of responsible officials: Management agrees with the finding and recommendation.