U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
Information on the Federal Program: Assistance Listing Number 10.561— State Administrative Matching Grants for Supplemental Nutrition Assistance Program, United States Department of Agriculture. Pass-Through Entity: Colorado Department of Human Services. Compliance Requirements: Allowable Cost and Activities. Type of Finding: Material Noncompliance and Significant Deficiency Criteria: Program requirements state that each program participants file should follow the record retention policies contained in the grant agreementand required under 2 CFR §200.333, to support conclusion on program eligibility. Condition: For the year ended June 30, 2023, we identified one program participant file that was not retained, and were unable to confirm if program participant was eligible, and services provided were supported in file. Cause: Program staff upon termination misplaced file, and it was unable to be tracked down during audit. Effect or Potential Effect: As a result, we were not able to verify program eligibility or if services provided were supported and allowable under the program for missing file. Questioned Costs: None. Context: Of the sixty participant files tested, we identified one that was not retained and available to review. Recommendation: The entity program staff and management should ensure record retention policies are enforced. Views of Responsible : We agree with the auditor’s finding that there was no documentation available to substantiate eligibility, however we believe our actions meet the requirements of the program. While we understand that documentation should be maintained, we do believe that the services provided were in compliance with applicable standards.
Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework,” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” As described in Title 2 Code of Federal Regulations (C.F.R.) § 200.333, financial records, supporting documents, statistical records and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three (3) years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient. In addition, 2 CFR Section 200.403 of the Uniform Guidance states the following regarding the factors affecting the allowability of costs: “Except where otherwise authorized by statue, costs must meet the following general criteria in order to be allowable under Federal awards: (g) Be adequately documented.” Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies, and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Cause: Management did not have sufficiently designed internal controls in place over the review and approval of average unit costs applied to FAM usage charged to the FEMA program. In addition, for 11 non-FAM (purchased equipment) transactions from fiscal year 2020 charged to the FEMA program, expenditure approvals were maintained in a legacy general ledger system and upon migration to the current general ledger system, the approval trail was not retained. For one other non-FAM (purchased equipment) transaction from fiscal year 2022 charged to the FEMA program, the required level of approvals of the purchase-card transaction was not retained. Effect or potential effect: For FAM costs, Mercy Health is not in compliance with the general criteria of maintaining adequate documentation that supports the average unit costs used in the calculation and determination of the costs charged to the federal program. For non-FAM costs, Mercy Health may not be compliant with the allowability of costs requirements of the FEMA program. Questioned costs: $45 – Assistance Listing No. 97.036 (COVID-19). Context: We sampled 40 FAM costs (totaling $2,826 in federal expenditures) and agreed the PPE inventory item’s usage to supporting requisition documentation. In addition, we obtained the external vendor invoice for the purchase of the PPE inventory item immediately prior to the usage of the PPE inventory item. However, for all 40 sampled FAM costs, we could not verify the average unit cost that is used in determining the amount charged to the FEMA program. The net overstatement of the costs based on the average unit cost for these 40 sampled FAM costs in comparison to the external vendor invoices was $45. In addition, we sampled 40 non-FAM costs (totaling $218,110 in federal expenditures) and noted that 12 purchased equipment transactions (totaling $182,048 in federal expenditures) did not have support retained to evidence review and approval of the expenditure for allowability. FAM costs and non-FAM costs represent 71% and 29%, respectively, of total federal expenditures for the FEMA program of $3,383,897 for the year ended June 30, 2023. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should design and implement effective internal controls over the review and approval of all costs charged to the FEMA program. Views of Responsible Officials: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will ensure all capital is reviewed and approved in Strata going forward.
Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework,” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” As described in Title 2 Code of Federal Regulations (C.F.R.) § 200.333, financial records, supporting documents, statistical records and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three (3) years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient. In addition, 2 CFR Section 200.403 of the Uniform Guidance states the following regarding the factors affecting the allowability of costs: “Except where otherwise authorized by statue, costs must meet the following general criteria in order to be allowable under Federal awards: (g) Be adequately documented.” Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies, and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Cause: Management did not have sufficiently designed internal controls in place over the review and approval of average unit costs applied to FAM usage charged to the FEMA program. In addition, for 11 non-FAM (purchased equipment) transactions from fiscal year 2020 charged to the FEMA program, expenditure approvals were maintained in a legacy general ledger system and upon migration to the current general ledger system, the approval trail was not retained. For one other non-FAM (purchased equipment) transaction from fiscal year 2022 charged to the FEMA program, the required level of approvals of the purchase-card transaction was not retained. Effect or potential effect: For FAM costs, Mercy Health is not in compliance with the general criteria of maintaining adequate documentation that supports the average unit costs used in the calculation and determination of the costs charged to the federal program. For non-FAM costs, Mercy Health may not be compliant with the allowability of costs requirements of the FEMA program. Questioned costs: $45 – Assistance Listing No. 97.036 (COVID-19). Context: We sampled 40 FAM costs (totaling $2,826 in federal expenditures) and agreed the PPE inventory item’s usage to supporting requisition documentation. In addition, we obtained the external vendor invoice for the purchase of the PPE inventory item immediately prior to the usage of the PPE inventory item. However, for all 40 sampled FAM costs, we could not verify the average unit cost that is used in determining the amount charged to the FEMA program. The net overstatement of the costs based on the average unit cost for these 40 sampled FAM costs in comparison to the external vendor invoices was $45. In addition, we sampled 40 non-FAM costs (totaling $218,110 in federal expenditures) and noted that 12 purchased equipment transactions (totaling $182,048 in federal expenditures) did not have support retained to evidence review and approval of the expenditure for allowability. FAM costs and non-FAM costs represent 71% and 29%, respectively, of total federal expenditures for the FEMA program of $3,383,897 for the year ended June 30, 2023. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should design and implement effective internal controls over the review and approval of all costs charged to the FEMA program. Views of Responsible Officials: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will ensure all capital is reviewed and approved in Strata going forward.
Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework,” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” As described in Title 2 Code of Federal Regulations (C.F.R.) § 200.333, financial records, supporting documents, statistical records and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three (3) years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient. In addition, 2 CFR Section 200.403 of the Uniform Guidance states the following regarding the factors affecting the allowability of costs: “Except where otherwise authorized by statue, costs must meet the following general criteria in order to be allowable under Federal awards: (g) Be adequately documented.” Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies, and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Cause: Management did not have sufficiently designed internal controls in place over the review and approval of average unit costs applied to FAM usage charged to the FEMA program. In addition, for 11 non-FAM (purchased equipment) transactions from fiscal year 2020 charged to the FEMA program, expenditure approvals were maintained in a legacy general ledger system and upon migration to the current general ledger system, the approval trail was not retained. For one other non-FAM (purchased equipment) transaction from fiscal year 2022 charged to the FEMA program, the required level of approvals of the purchase-card transaction was not retained. Effect or potential effect: For FAM costs, Mercy Health is not in compliance with the general criteria of maintaining adequate documentation that supports the average unit costs used in the calculation and determination of the costs charged to the federal program. For non-FAM costs, Mercy Health may not be compliant with the allowability of costs requirements of the FEMA program. Questioned costs: $45 – Assistance Listing No. 97.036 (COVID-19). Context: We sampled 40 FAM costs (totaling $2,826 in federal expenditures) and agreed the PPE inventory item’s usage to supporting requisition documentation. In addition, we obtained the external vendor invoice for the purchase of the PPE inventory item immediately prior to the usage of the PPE inventory item. However, for all 40 sampled FAM costs, we could not verify the average unit cost that is used in determining the amount charged to the FEMA program. The net overstatement of the costs based on the average unit cost for these 40 sampled FAM costs in comparison to the external vendor invoices was $45. In addition, we sampled 40 non-FAM costs (totaling $218,110 in federal expenditures) and noted that 12 purchased equipment transactions (totaling $182,048 in federal expenditures) did not have support retained to evidence review and approval of the expenditure for allowability. FAM costs and non-FAM costs represent 71% and 29%, respectively, of total federal expenditures for the FEMA program of $3,383,897 for the year ended June 30, 2023. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should design and implement effective internal controls over the review and approval of all costs charged to the FEMA program. Views of Responsible Officials: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will ensure all capital is reviewed and approved in Strata going forward.
Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework,” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” As described in Title 2 Code of Federal Regulations (C.F.R.) § 200.333, financial records, supporting documents, statistical records and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three (3) years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient. In addition, 2 CFR Section 200.403 of the Uniform Guidance states the following regarding the factors affecting the allowability of costs: “Except where otherwise authorized by statue, costs must meet the following general criteria in order to be allowable under Federal awards: (g) Be adequately documented.” Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies, and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Cause: Management did not have sufficiently designed internal controls in place over the review and approval of average unit costs applied to FAM usage charged to the FEMA program. In addition, for 11 non-FAM (purchased equipment) transactions from fiscal year 2020 charged to the FEMA program, expenditure approvals were maintained in a legacy general ledger system and upon migration to the current general ledger system, the approval trail was not retained. For one other non-FAM (purchased equipment) transaction from fiscal year 2022 charged to the FEMA program, the required level of approvals of the purchase-card transaction was not retained. Effect or potential effect: For FAM costs, Mercy Health is not in compliance with the general criteria of maintaining adequate documentation that supports the average unit costs used in the calculation and determination of the costs charged to the federal program. For non-FAM costs, Mercy Health may not be compliant with the allowability of costs requirements of the FEMA program. Questioned costs: $45 – Assistance Listing No. 97.036 (COVID-19). Context: We sampled 40 FAM costs (totaling $2,826 in federal expenditures) and agreed the PPE inventory item’s usage to supporting requisition documentation. In addition, we obtained the external vendor invoice for the purchase of the PPE inventory item immediately prior to the usage of the PPE inventory item. However, for all 40 sampled FAM costs, we could not verify the average unit cost that is used in determining the amount charged to the FEMA program. The net overstatement of the costs based on the average unit cost for these 40 sampled FAM costs in comparison to the external vendor invoices was $45. In addition, we sampled 40 non-FAM costs (totaling $218,110 in federal expenditures) and noted that 12 purchased equipment transactions (totaling $182,048 in federal expenditures) did not have support retained to evidence review and approval of the expenditure for allowability. FAM costs and non-FAM costs represent 71% and 29%, respectively, of total federal expenditures for the FEMA program of $3,383,897 for the year ended June 30, 2023. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should design and implement effective internal controls over the review and approval of all costs charged to the FEMA program. Views of Responsible Officials: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will ensure all capital is reviewed and approved in Strata going forward.
Condition Two employees were paid wages for activities coded to special education: For one of the two special education employees tested, Ha:San prepared an employment contract, however, they were not signed by the employee or a school administrator. For the other employee tested, Ha:San could not provide evidence it prepared or retained an employment contract to support the employee designation to provide special education services. For all seven timecards tested for both employees the timecards did not contain a signature from either the employee or a School administrator. Criteria Accounting best practices specifies that supporting documentation should be prepared and retained to support all transactions. The Internal Revenue Service explains "An exempt organization must keep books and records needed to show that it complies with the tax rules. The organization must be able to document the sources of receipts and expenditures reported on its annual return and on any tax returns it must file. Records must support income, expenses, and credits reported on exempt organization annual returns and tax returns." Uniform Guidance §200.333 Retention requirements for records states in part: "Financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three years from the date of submission of the final expenditure report..."must be based on records that accurately reflect the work performed. These records must: (i) Be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. 2 CFR 200.430(i)(1)(vii) states: "Support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are located using different allocation bases; or an unallowable activity and a direct or indirect cost activity." Cause There was a period of significant turnover in the administrative office for the past year. During the transition, existing controls were not followed to ensure complete documentation was retained. Effect Financial information Ha:San uses to make decisions and reports provided to the state of Arizona for oversight could have been materially misstated throughout the fiscal year. Further, Ha:San could end up being in noncompliance with federal and state laws. Recommendation Ha:San should procure a consultant or modify the organizational chart of the finance office to ensure individuals with the skills, knowledge and expertise prepare, review and retain required source documentation.
Federal Agency: U.S. Department of Commerce Federal Program: Economic Development Cluster Assistance Listing 11.307 COVID-19–Economic Adjustment Assistance EDA Award No. 08-79-05412 Criteria or specific requirement: Subrecipient Monitoring (2 CFR 200.331 - 200.333) and Reporting (2 CFR Part 170). Under the requirements of the Federal Funding Accountability and Transparency Act (FFATA) (Pub. L. No. 109-282), as amended by Section 6202 of Pub. L. No. 110-252, hereafter referred to as the “Transparency Act” that are codified in 2 CFR Part 170, recipients (i.e., direct recipients) of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Condition: The Organization subawarded a portion of this award with out written approval from the Economic Development Administration. The Organization also failed to file the FFATA reporting submission for the fiscal year ended June 30, 2023. Questioned Costs: $215,000 Context: The Organization did not obtain approval or report the subaward information for the one subrecipient that received $215,000 in fiscal year 2023. Effect: The noncompliance could have a direct and material effect on the financial statements. Cause: The Organization did not have adequate controls or procedures in place to identify the applicable subrecipient monitoring and reporting requirements and ensure the information was filed accurately and timely. Identification as a Repeat Finding, if Applicable: Not applicable. Recommendation: We recommend implementing procedures and controls to ensure subrecipient monitoring and reporting requirements are monitored and required reports are filed by their respective due dates as required by the grant agreement and Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management concurs with the finding and recommendation. See separate report for planned corrective actions.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
U.S. Department of Labor Iowa Workforce Development Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Subrecipient monitoring requirements are contained in 2 CFR 200.331 through 2 CFR 200.333 and include requirements to identify the award and applicable requirements to the subrecipient and monitor the activities of the subrecipient. Condition – Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Cause – The County did not have an internal control process in place to ensure subrecipient monitoring requirements were met. Effect – Without the proper communication of applicable requirements and monitoring of the subrecipient, there is a possibility that federal statutes, regulations, and the terms and conditions of the federal award were not complied with. Questioned Costs – None reported. Context/Sampling – $1,437,054 was passed through to one subrecipient during the year ended June 30, 2023. Repeat Finding from Prior Years – Yes. Recommendation – We recommend the County implement a control process which includes the applicable subrecipient monitoring requirements. View of Responsible Officials – This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023.
FINDING NO: 2023-074 (Repeat Finding 2022-014) STATE AGENCY: Department of Human Services FEDERAL AGENCY: United States Department of Health and Human Services ALN: 93.575 , 93.596 FEDERAL PROGRAM NAME: CCDF Cluster FEDERAL AWARD NUMBER: 2201OKCCDF and 2301OKCCDF FEDERAL AWARD YEAR: 2022 and 2023 CONTROL CATEGORY: Special Tests and Provisions - Health and Safety Requirements QUESTIONED COSTS: $0 Criteria: CFR 45 §98.41 Health and safety requirements states, in part, “(a) Each Lead Agency shall certify that there are in effect, within the State (or other area served by the Lead Agency), under State, local or tribal law, requirements (appropriate to provider setting and age of children served) that are designed, implemented, and enforced to protect the health and safety of children. Such requirements must be applicable to child care providers of services for which assistance is provided under this part. Such requirements, which are subject to monitoring pursuant to §98.42, shall: (1) Include health and safety topics consisting of, at a minimum: (i) The prevention and control of infectious diseases (including immunizations); with respect to immunizations, the following provisions apply: (A) As part of their health and safety provisions in this area, Lead Agencies shall assure that children receiving services under the CCDF are age-appropriately immunized. Those health and safety provisions shall incorporate (by reference or otherwise) the latest recommendation for childhood immunizations of the respective State, territorial, or tribal public health agency. (B) Notwithstanding this paragraph (a)(1)(i), Lead Agencies may exempt: (1) Children who are cared for by relatives (defined as grandparents, great grandparents, siblings (if living in a separate residence), aunts, and uncles), provided there are no other unrelated children who are cared for in the same setting. (2) Children who receive care in their own homes, provided there are no other unrelated children who are cared for in the home. (3) Children whose parents object to immunization on religious grounds. (4) Children whose medical condition contraindicates immunization. (C) Lead Agencies shall establish a grace period that allows children experiencing homelessness and children in foster care to receive services under this part while providing their families (including foster families) a reasonable time to take any necessary action to comply with immunization and other health and safety requirements. (1) The length of such grace period shall be established in consultation with the State, Territorial or Tribal health agency. (2) Any payment for such child during the grace period shall not be considered an error or improper payment under subpart K of this part. (3) The Lead Agency may also, at its option, establish grace periods for other children who are not experiencing homelessness or in foster care. (4) Lead Agencies must coordinate with licensing agencies and other relevant State, Territorial, Tribal, and local agencies to provide referrals and support to help families of children receiving services during a grace period comply with immunization and other health and safety requirements; (ii) Prevention of sudden infant death syndrome and use of safe sleeping practices; (iii) Administration of medication, consistent with standards for parental consent; (iv) Prevention and response to emergencies due to food and allergic reactions; (v) Building and physical premises safety, including identification of and protection from hazards, bodies of water, and vehicular traffic; (vi) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; (vii) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a mancaused event (such as violence at a child care facility), within the meaning of those terms under section 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. 5195a(a)(1)) that shall include procedures for evacuation, relocation, shelter-in-place and lock down, staff and volunteer emergency preparedness training and practice drills, communication and reunification with families, continuity of operations, and accommodation of infants and toddlers, children with disabilities, and children with chronic medical conditions; (viii) Handling and storage of hazardous materials and the appropriate disposal of bio contaminants; (ix) Appropriate precautions in transporting children, if applicable; (x) Pediatric first aid and cardiopulmonary resuscitation; (xi) Recognition and reporting of child abuse and neglect, in accordance with the requirement in paragraph (e) of this section; and … .” OAC 340:110-3-11(a)(8) states in part, “Ongoing approvals by fire and health are required every two years.” OAC 340:110-1-9 (b) states, “Ongoing monitoring: During monitoring visits, the licensing staff observes the entire facility, including outdoor play space and vehicles used for transportation, if available. At or subsequent to each visit, licensing staff checks: • (1) compliance with licensing regulations; • (2) records for new staff including personnel sheets and compliance with background investigations per OAC 340:110-1-8.1; • (3) personnel professional development records; • (4) Oklahoma Department of Human Services (OKDHS) computer checks on applicable persons per OAC 340:110-1-8.1; • (5) fire and health inspections within the last 24 months, (when) applicable; • (6) Form 07LC092E, Insurance Verification, within the last 12 months, or posting of Form 07LC093E, Insurance Exception Notification; and • (7) other documentation requiring renewal.” Instructions to Staff OAC 340:110-1-9(3) states in part, “Licensing staff: (1) documents observations and discussions on the appropriate monitoring checklists, enters the information from the monitoring checklists onto the licensing database, provides copies of the monitoring summary to the program’s owner/operator and files the original in the program’s file in the local Oklahoma Department of Human Services (OKDHS) office.” 2 CFR 200.333 states, “Financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three years from the date of submission of the final expenditures report, or for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient.” Condition and Context: We noted the following for a sample of 72 of 1,988 daycare centers and homes: • 68 centers/homes (94.44%) for which we could not determine, for at least one of their monitoring checklists, that the checklists were adequately documented in relation to compliance with the health and safety requirements • 6 centers/home (8.33%) for which the smoke detector was not tested during the visit and was not noted as non-compliance • 8 centers/home (11.11%) for which the carbon monoxide was not tested during the visit and was not noted as non-compliance • 6 centers/home (8.33%) for which the fire inspection was not up to date, and was not noted as non-compliance • 2 centers/home (2.77%) for which the physical environment checklist was not up to date and was not noted as non-compliance • 3 centers/home (4.16%) for which the annual insurance expiration date or exception declared date was not noted in the monitoring checklist • 6 centers/home (8.33%) for which the fire extinguisher was expired and was not noted as non-compliance • 3 centers/home (4.16%) for which the health inspection visit was not up to date and was not noted as noncompliance • 2 centers/home (2.77%) for which the equipment inventory completion was not up to date and was not noted as non-compliance • 6 centers/homes (8.33%) for which the number of visits were not performed according to the Monitoring Frequency Plan (MFP). During our walk-through of the monitoring checklist software application in prior audits, we observed a drop-down box containing the requirements applicable to each header. When non-compliance was noted during monitoring, the monitoring specialist would mark the corresponding requirement in the drop-down box as well as “NC” beside the header. However, we noted that if ‘NC’ is not marked in the header, the non-compliance will not be carried forward to the monitoring summary report that is reviewed and signed by the center/home administrator and the monitoring specialist. In addition, we could not determine that the tracking mechanism for monitoring visits was consistently used to ensure that all daycare facilities and homes are monitored in accordance with their applicable Monitoring Frequency Plan (MFP) or that follow-up takes place when non-compliance is noted. Work plan reports are generated in the Child Care Monitoring, Administration and Safety System (CCMASS) to assist with tracking monitoring visits, pending complaints, and Star review visits to be conducted; however, these are not retained by the licensing specialist, so we were unable to verify their use. Cause: Prior to January 30, 2023, the monitoring checklists and summary reports were not sufficiently designed to allow a reviewer to see what has been observed. Additionally, a uniform system to track monitoring visits and noncompliance follow-up has been designed, but the Agency does not require monitors to use it. Effect: The agency is not in compliance with the above stated requirements. If health and safety requirements are not met at each home/center, children in these facilities are at risk for illness and injury. Further, lack of a required comparison back to the work plan reports could result in potentially insufficient monitoring of facilities. Recommendation: We recommend the agency implement procedures to ensure all monitoring visits are documented in a manner that clearly conveys all health and safety requirements were reviewed for the facility. In addition, we recommend training be provided to all monitoring staff to ensure all monitoring visits are performed in a consistent manner and are adequately documented. Further, we recommend the importance of the use of the work plan report and the retention of these real time documents be emphasized to all staff. Views of Responsible Official(s) Contact Person: Dione Smith Anticipated Completion Date: January 30th, 2023 Corrective Action Planned: The Department of Human Services agrees with the finding. Please see the corrective action plan located in the corrective action plan section of this report.
FINDING NO: 2023-074 (Repeat Finding 2022-014) STATE AGENCY: Department of Human Services FEDERAL AGENCY: United States Department of Health and Human Services ALN: 93.575 , 93.596 FEDERAL PROGRAM NAME: CCDF Cluster FEDERAL AWARD NUMBER: 2201OKCCDF and 2301OKCCDF FEDERAL AWARD YEAR: 2022 and 2023 CONTROL CATEGORY: Special Tests and Provisions - Health and Safety Requirements QUESTIONED COSTS: $0 Criteria: CFR 45 §98.41 Health and safety requirements states, in part, “(a) Each Lead Agency shall certify that there are in effect, within the State (or other area served by the Lead Agency), under State, local or tribal law, requirements (appropriate to provider setting and age of children served) that are designed, implemented, and enforced to protect the health and safety of children. Such requirements must be applicable to child care providers of services for which assistance is provided under this part. Such requirements, which are subject to monitoring pursuant to §98.42, shall: (1) Include health and safety topics consisting of, at a minimum: (i) The prevention and control of infectious diseases (including immunizations); with respect to immunizations, the following provisions apply: (A) As part of their health and safety provisions in this area, Lead Agencies shall assure that children receiving services under the CCDF are age-appropriately immunized. Those health and safety provisions shall incorporate (by reference or otherwise) the latest recommendation for childhood immunizations of the respective State, territorial, or tribal public health agency. (B) Notwithstanding this paragraph (a)(1)(i), Lead Agencies may exempt: (1) Children who are cared for by relatives (defined as grandparents, great grandparents, siblings (if living in a separate residence), aunts, and uncles), provided there are no other unrelated children who are cared for in the same setting. (2) Children who receive care in their own homes, provided there are no other unrelated children who are cared for in the home. (3) Children whose parents object to immunization on religious grounds. (4) Children whose medical condition contraindicates immunization. (C) Lead Agencies shall establish a grace period that allows children experiencing homelessness and children in foster care to receive services under this part while providing their families (including foster families) a reasonable time to take any necessary action to comply with immunization and other health and safety requirements. (1) The length of such grace period shall be established in consultation with the State, Territorial or Tribal health agency. (2) Any payment for such child during the grace period shall not be considered an error or improper payment under subpart K of this part. (3) The Lead Agency may also, at its option, establish grace periods for other children who are not experiencing homelessness or in foster care. (4) Lead Agencies must coordinate with licensing agencies and other relevant State, Territorial, Tribal, and local agencies to provide referrals and support to help families of children receiving services during a grace period comply with immunization and other health and safety requirements; (ii) Prevention of sudden infant death syndrome and use of safe sleeping practices; (iii) Administration of medication, consistent with standards for parental consent; (iv) Prevention and response to emergencies due to food and allergic reactions; (v) Building and physical premises safety, including identification of and protection from hazards, bodies of water, and vehicular traffic; (vi) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; (vii) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a mancaused event (such as violence at a child care facility), within the meaning of those terms under section 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. 5195a(a)(1)) that shall include procedures for evacuation, relocation, shelter-in-place and lock down, staff and volunteer emergency preparedness training and practice drills, communication and reunification with families, continuity of operations, and accommodation of infants and toddlers, children with disabilities, and children with chronic medical conditions; (viii) Handling and storage of hazardous materials and the appropriate disposal of bio contaminants; (ix) Appropriate precautions in transporting children, if applicable; (x) Pediatric first aid and cardiopulmonary resuscitation; (xi) Recognition and reporting of child abuse and neglect, in accordance with the requirement in paragraph (e) of this section; and … .” OAC 340:110-3-11(a)(8) states in part, “Ongoing approvals by fire and health are required every two years.” OAC 340:110-1-9 (b) states, “Ongoing monitoring: During monitoring visits, the licensing staff observes the entire facility, including outdoor play space and vehicles used for transportation, if available. At or subsequent to each visit, licensing staff checks: • (1) compliance with licensing regulations; • (2) records for new staff including personnel sheets and compliance with background investigations per OAC 340:110-1-8.1; • (3) personnel professional development records; • (4) Oklahoma Department of Human Services (OKDHS) computer checks on applicable persons per OAC 340:110-1-8.1; • (5) fire and health inspections within the last 24 months, (when) applicable; • (6) Form 07LC092E, Insurance Verification, within the last 12 months, or posting of Form 07LC093E, Insurance Exception Notification; and • (7) other documentation requiring renewal.” Instructions to Staff OAC 340:110-1-9(3) states in part, “Licensing staff: (1) documents observations and discussions on the appropriate monitoring checklists, enters the information from the monitoring checklists onto the licensing database, provides copies of the monitoring summary to the program’s owner/operator and files the original in the program’s file in the local Oklahoma Department of Human Services (OKDHS) office.” 2 CFR 200.333 states, “Financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three years from the date of submission of the final expenditures report, or for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient.” Condition and Context: We noted the following for a sample of 72 of 1,988 daycare centers and homes: • 68 centers/homes (94.44%) for which we could not determine, for at least one of their monitoring checklists, that the checklists were adequately documented in relation to compliance with the health and safety requirements • 6 centers/home (8.33%) for which the smoke detector was not tested during the visit and was not noted as non-compliance • 8 centers/home (11.11%) for which the carbon monoxide was not tested during the visit and was not noted as non-compliance • 6 centers/home (8.33%) for which the fire inspection was not up to date, and was not noted as non-compliance • 2 centers/home (2.77%) for which the physical environment checklist was not up to date and was not noted as non-compliance • 3 centers/home (4.16%) for which the annual insurance expiration date or exception declared date was not noted in the monitoring checklist • 6 centers/home (8.33%) for which the fire extinguisher was expired and was not noted as non-compliance • 3 centers/home (4.16%) for which the health inspection visit was not up to date and was not noted as noncompliance • 2 centers/home (2.77%) for which the equipment inventory completion was not up to date and was not noted as non-compliance • 6 centers/homes (8.33%) for which the number of visits were not performed according to the Monitoring Frequency Plan (MFP). During our walk-through of the monitoring checklist software application in prior audits, we observed a drop-down box containing the requirements applicable to each header. When non-compliance was noted during monitoring, the monitoring specialist would mark the corresponding requirement in the drop-down box as well as “NC” beside the header. However, we noted that if ‘NC’ is not marked in the header, the non-compliance will not be carried forward to the monitoring summary report that is reviewed and signed by the center/home administrator and the monitoring specialist. In addition, we could not determine that the tracking mechanism for monitoring visits was consistently used to ensure that all daycare facilities and homes are monitored in accordance with their applicable Monitoring Frequency Plan (MFP) or that follow-up takes place when non-compliance is noted. Work plan reports are generated in the Child Care Monitoring, Administration and Safety System (CCMASS) to assist with tracking monitoring visits, pending complaints, and Star review visits to be conducted; however, these are not retained by the licensing specialist, so we were unable to verify their use. Cause: Prior to January 30, 2023, the monitoring checklists and summary reports were not sufficiently designed to allow a reviewer to see what has been observed. Additionally, a uniform system to track monitoring visits and noncompliance follow-up has been designed, but the Agency does not require monitors to use it. Effect: The agency is not in compliance with the above stated requirements. If health and safety requirements are not met at each home/center, children in these facilities are at risk for illness and injury. Further, lack of a required comparison back to the work plan reports could result in potentially insufficient monitoring of facilities. Recommendation: We recommend the agency implement procedures to ensure all monitoring visits are documented in a manner that clearly conveys all health and safety requirements were reviewed for the facility. In addition, we recommend training be provided to all monitoring staff to ensure all monitoring visits are performed in a consistent manner and are adequately documented. Further, we recommend the importance of the use of the work plan report and the retention of these real time documents be emphasized to all staff. Views of Responsible Official(s) Contact Person: Dione Smith Anticipated Completion Date: January 30th, 2023 Corrective Action Planned: The Department of Human Services agrees with the finding. Please see the corrective action plan located in the corrective action plan section of this report.
FINDING NO: 2023-074 (Repeat Finding 2022-014) STATE AGENCY: Department of Human Services FEDERAL AGENCY: United States Department of Health and Human Services ALN: 93.575 , 93.596 FEDERAL PROGRAM NAME: CCDF Cluster FEDERAL AWARD NUMBER: 2201OKCCDF and 2301OKCCDF FEDERAL AWARD YEAR: 2022 and 2023 CONTROL CATEGORY: Special Tests and Provisions - Health and Safety Requirements QUESTIONED COSTS: $0 Criteria: CFR 45 §98.41 Health and safety requirements states, in part, “(a) Each Lead Agency shall certify that there are in effect, within the State (or other area served by the Lead Agency), under State, local or tribal law, requirements (appropriate to provider setting and age of children served) that are designed, implemented, and enforced to protect the health and safety of children. Such requirements must be applicable to child care providers of services for which assistance is provided under this part. Such requirements, which are subject to monitoring pursuant to §98.42, shall: (1) Include health and safety topics consisting of, at a minimum: (i) The prevention and control of infectious diseases (including immunizations); with respect to immunizations, the following provisions apply: (A) As part of their health and safety provisions in this area, Lead Agencies shall assure that children receiving services under the CCDF are age-appropriately immunized. Those health and safety provisions shall incorporate (by reference or otherwise) the latest recommendation for childhood immunizations of the respective State, territorial, or tribal public health agency. (B) Notwithstanding this paragraph (a)(1)(i), Lead Agencies may exempt: (1) Children who are cared for by relatives (defined as grandparents, great grandparents, siblings (if living in a separate residence), aunts, and uncles), provided there are no other unrelated children who are cared for in the same setting. (2) Children who receive care in their own homes, provided there are no other unrelated children who are cared for in the home. (3) Children whose parents object to immunization on religious grounds. (4) Children whose medical condition contraindicates immunization. (C) Lead Agencies shall establish a grace period that allows children experiencing homelessness and children in foster care to receive services under this part while providing their families (including foster families) a reasonable time to take any necessary action to comply with immunization and other health and safety requirements. (1) The length of such grace period shall be established in consultation with the State, Territorial or Tribal health agency. (2) Any payment for such child during the grace period shall not be considered an error or improper payment under subpart K of this part. (3) The Lead Agency may also, at its option, establish grace periods for other children who are not experiencing homelessness or in foster care. (4) Lead Agencies must coordinate with licensing agencies and other relevant State, Territorial, Tribal, and local agencies to provide referrals and support to help families of children receiving services during a grace period comply with immunization and other health and safety requirements; (ii) Prevention of sudden infant death syndrome and use of safe sleeping practices; (iii) Administration of medication, consistent with standards for parental consent; (iv) Prevention and response to emergencies due to food and allergic reactions; (v) Building and physical premises safety, including identification of and protection from hazards, bodies of water, and vehicular traffic; (vi) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; (vii) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a mancaused event (such as violence at a child care facility), within the meaning of those terms under section 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. 5195a(a)(1)) that shall include procedures for evacuation, relocation, shelter-in-place and lock down, staff and volunteer emergency preparedness training and practice drills, communication and reunification with families, continuity of operations, and accommodation of infants and toddlers, children with disabilities, and children with chronic medical conditions; (viii) Handling and storage of hazardous materials and the appropriate disposal of bio contaminants; (ix) Appropriate precautions in transporting children, if applicable; (x) Pediatric first aid and cardiopulmonary resuscitation; (xi) Recognition and reporting of child abuse and neglect, in accordance with the requirement in paragraph (e) of this section; and … .” OAC 340:110-3-11(a)(8) states in part, “Ongoing approvals by fire and health are required every two years.” OAC 340:110-1-9 (b) states, “Ongoing monitoring: During monitoring visits, the licensing staff observes the entire facility, including outdoor play space and vehicles used for transportation, if available. At or subsequent to each visit, licensing staff checks: • (1) compliance with licensing regulations; • (2) records for new staff including personnel sheets and compliance with background investigations per OAC 340:110-1-8.1; • (3) personnel professional development records; • (4) Oklahoma Department of Human Services (OKDHS) computer checks on applicable persons per OAC 340:110-1-8.1; • (5) fire and health inspections within the last 24 months, (when) applicable; • (6) Form 07LC092E, Insurance Verification, within the last 12 months, or posting of Form 07LC093E, Insurance Exception Notification; and • (7) other documentation requiring renewal.” Instructions to Staff OAC 340:110-1-9(3) states in part, “Licensing staff: (1) documents observations and discussions on the appropriate monitoring checklists, enters the information from the monitoring checklists onto the licensing database, provides copies of the monitoring summary to the program’s owner/operator and files the original in the program’s file in the local Oklahoma Department of Human Services (OKDHS) office.” 2 CFR 200.333 states, “Financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three years from the date of submission of the final expenditures report, or for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient.” Condition and Context: We noted the following for a sample of 72 of 1,988 daycare centers and homes: • 68 centers/homes (94.44%) for which we could not determine, for at least one of their monitoring checklists, that the checklists were adequately documented in relation to compliance with the health and safety requirements • 6 centers/home (8.33%) for which the smoke detector was not tested during the visit and was not noted as non-compliance • 8 centers/home (11.11%) for which the carbon monoxide was not tested during the visit and was not noted as non-compliance • 6 centers/home (8.33%) for which the fire inspection was not up to date, and was not noted as non-compliance • 2 centers/home (2.77%) for which the physical environment checklist was not up to date and was not noted as non-compliance • 3 centers/home (4.16%) for which the annual insurance expiration date or exception declared date was not noted in the monitoring checklist • 6 centers/home (8.33%) for which the fire extinguisher was expired and was not noted as non-compliance • 3 centers/home (4.16%) for which the health inspection visit was not up to date and was not noted as noncompliance • 2 centers/home (2.77%) for which the equipment inventory completion was not up to date and was not noted as non-compliance • 6 centers/homes (8.33%) for which the number of visits were not performed according to the Monitoring Frequency Plan (MFP). During our walk-through of the monitoring checklist software application in prior audits, we observed a drop-down box containing the requirements applicable to each header. When non-compliance was noted during monitoring, the monitoring specialist would mark the corresponding requirement in the drop-down box as well as “NC” beside the header. However, we noted that if ‘NC’ is not marked in the header, the non-compliance will not be carried forward to the monitoring summary report that is reviewed and signed by the center/home administrator and the monitoring specialist. In addition, we could not determine that the tracking mechanism for monitoring visits was consistently used to ensure that all daycare facilities and homes are monitored in accordance with their applicable Monitoring Frequency Plan (MFP) or that follow-up takes place when non-compliance is noted. Work plan reports are generated in the Child Care Monitoring, Administration and Safety System (CCMASS) to assist with tracking monitoring visits, pending complaints, and Star review visits to be conducted; however, these are not retained by the licensing specialist, so we were unable to verify their use. Cause: Prior to January 30, 2023, the monitoring checklists and summary reports were not sufficiently designed to allow a reviewer to see what has been observed. Additionally, a uniform system to track monitoring visits and noncompliance follow-up has been designed, but the Agency does not require monitors to use it. Effect: The agency is not in compliance with the above stated requirements. If health and safety requirements are not met at each home/center, children in these facilities are at risk for illness and injury. Further, lack of a required comparison back to the work plan reports could result in potentially insufficient monitoring of facilities. Recommendation: We recommend the agency implement procedures to ensure all monitoring visits are documented in a manner that clearly conveys all health and safety requirements were reviewed for the facility. In addition, we recommend training be provided to all monitoring staff to ensure all monitoring visits are performed in a consistent manner and are adequately documented. Further, we recommend the importance of the use of the work plan report and the retention of these real time documents be emphasized to all staff. Views of Responsible Official(s) Contact Person: Dione Smith Anticipated Completion Date: January 30th, 2023 Corrective Action Planned: The Department of Human Services agrees with the finding. Please see the corrective action plan located in the corrective action plan section of this report.
FINDING NO: 2023-074 (Repeat Finding 2022-014) STATE AGENCY: Department of Human Services FEDERAL AGENCY: United States Department of Health and Human Services ALN: 93.575 , 93.596 FEDERAL PROGRAM NAME: CCDF Cluster FEDERAL AWARD NUMBER: 2201OKCCDF and 2301OKCCDF FEDERAL AWARD YEAR: 2022 and 2023 CONTROL CATEGORY: Special Tests and Provisions - Health and Safety Requirements QUESTIONED COSTS: $0 Criteria: CFR 45 §98.41 Health and safety requirements states, in part, “(a) Each Lead Agency shall certify that there are in effect, within the State (or other area served by the Lead Agency), under State, local or tribal law, requirements (appropriate to provider setting and age of children served) that are designed, implemented, and enforced to protect the health and safety of children. Such requirements must be applicable to child care providers of services for which assistance is provided under this part. Such requirements, which are subject to monitoring pursuant to §98.42, shall: (1) Include health and safety topics consisting of, at a minimum: (i) The prevention and control of infectious diseases (including immunizations); with respect to immunizations, the following provisions apply: (A) As part of their health and safety provisions in this area, Lead Agencies shall assure that children receiving services under the CCDF are age-appropriately immunized. Those health and safety provisions shall incorporate (by reference or otherwise) the latest recommendation for childhood immunizations of the respective State, territorial, or tribal public health agency. (B) Notwithstanding this paragraph (a)(1)(i), Lead Agencies may exempt: (1) Children who are cared for by relatives (defined as grandparents, great grandparents, siblings (if living in a separate residence), aunts, and uncles), provided there are no other unrelated children who are cared for in the same setting. (2) Children who receive care in their own homes, provided there are no other unrelated children who are cared for in the home. (3) Children whose parents object to immunization on religious grounds. (4) Children whose medical condition contraindicates immunization. (C) Lead Agencies shall establish a grace period that allows children experiencing homelessness and children in foster care to receive services under this part while providing their families (including foster families) a reasonable time to take any necessary action to comply with immunization and other health and safety requirements. (1) The length of such grace period shall be established in consultation with the State, Territorial or Tribal health agency. (2) Any payment for such child during the grace period shall not be considered an error or improper payment under subpart K of this part. (3) The Lead Agency may also, at its option, establish grace periods for other children who are not experiencing homelessness or in foster care. (4) Lead Agencies must coordinate with licensing agencies and other relevant State, Territorial, Tribal, and local agencies to provide referrals and support to help families of children receiving services during a grace period comply with immunization and other health and safety requirements; (ii) Prevention of sudden infant death syndrome and use of safe sleeping practices; (iii) Administration of medication, consistent with standards for parental consent; (iv) Prevention and response to emergencies due to food and allergic reactions; (v) Building and physical premises safety, including identification of and protection from hazards, bodies of water, and vehicular traffic; (vi) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; (vii) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a mancaused event (such as violence at a child care facility), within the meaning of those terms under section 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. 5195a(a)(1)) that shall include procedures for evacuation, relocation, shelter-in-place and lock down, staff and volunteer emergency preparedness training and practice drills, communication and reunification with families, continuity of operations, and accommodation of infants and toddlers, children with disabilities, and children with chronic medical conditions; (viii) Handling and storage of hazardous materials and the appropriate disposal of bio contaminants; (ix) Appropriate precautions in transporting children, if applicable; (x) Pediatric first aid and cardiopulmonary resuscitation; (xi) Recognition and reporting of child abuse and neglect, in accordance with the requirement in paragraph (e) of this section; and … .” OAC 340:110-3-11(a)(8) states in part, “Ongoing approvals by fire and health are required every two years.” OAC 340:110-1-9 (b) states, “Ongoing monitoring: During monitoring visits, the licensing staff observes the entire facility, including outdoor play space and vehicles used for transportation, if available. At or subsequent to each visit, licensing staff checks: • (1) compliance with licensing regulations; • (2) records for new staff including personnel sheets and compliance with background investigations per OAC 340:110-1-8.1; • (3) personnel professional development records; • (4) Oklahoma Department of Human Services (OKDHS) computer checks on applicable persons per OAC 340:110-1-8.1; • (5) fire and health inspections within the last 24 months, (when) applicable; • (6) Form 07LC092E, Insurance Verification, within the last 12 months, or posting of Form 07LC093E, Insurance Exception Notification; and • (7) other documentation requiring renewal.” Instructions to Staff OAC 340:110-1-9(3) states in part, “Licensing staff: (1) documents observations and discussions on the appropriate monitoring checklists, enters the information from the monitoring checklists onto the licensing database, provides copies of the monitoring summary to the program’s owner/operator and files the original in the program’s file in the local Oklahoma Department of Human Services (OKDHS) office.” 2 CFR 200.333 states, “Financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three years from the date of submission of the final expenditures report, or for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient.” Condition and Context: We noted the following for a sample of 72 of 1,988 daycare centers and homes: • 68 centers/homes (94.44%) for which we could not determine, for at least one of their monitoring checklists, that the checklists were adequately documented in relation to compliance with the health and safety requirements • 6 centers/home (8.33%) for which the smoke detector was not tested during the visit and was not noted as non-compliance • 8 centers/home (11.11%) for which the carbon monoxide was not tested during the visit and was not noted as non-compliance • 6 centers/home (8.33%) for which the fire inspection was not up to date, and was not noted as non-compliance • 2 centers/home (2.77%) for which the physical environment checklist was not up to date and was not noted as non-compliance • 3 centers/home (4.16%) for which the annual insurance expiration date or exception declared date was not noted in the monitoring checklist • 6 centers/home (8.33%) for which the fire extinguisher was expired and was not noted as non-compliance • 3 centers/home (4.16%) for which the health inspection visit was not up to date and was not noted as noncompliance • 2 centers/home (2.77%) for which the equipment inventory completion was not up to date and was not noted as non-compliance • 6 centers/homes (8.33%) for which the number of visits were not performed according to the Monitoring Frequency Plan (MFP). During our walk-through of the monitoring checklist software application in prior audits, we observed a drop-down box containing the requirements applicable to each header. When non-compliance was noted during monitoring, the monitoring specialist would mark the corresponding requirement in the drop-down box as well as “NC” beside the header. However, we noted that if ‘NC’ is not marked in the header, the non-compliance will not be carried forward to the monitoring summary report that is reviewed and signed by the center/home administrator and the monitoring specialist. In addition, we could not determine that the tracking mechanism for monitoring visits was consistently used to ensure that all daycare facilities and homes are monitored in accordance with their applicable Monitoring Frequency Plan (MFP) or that follow-up takes place when non-compliance is noted. Work plan reports are generated in the Child Care Monitoring, Administration and Safety System (CCMASS) to assist with tracking monitoring visits, pending complaints, and Star review visits to be conducted; however, these are not retained by the licensing specialist, so we were unable to verify their use. Cause: Prior to January 30, 2023, the monitoring checklists and summary reports were not sufficiently designed to allow a reviewer to see what has been observed. Additionally, a uniform system to track monitoring visits and noncompliance follow-up has been designed, but the Agency does not require monitors to use it. Effect: The agency is not in compliance with the above stated requirements. If health and safety requirements are not met at each home/center, children in these facilities are at risk for illness and injury. Further, lack of a required comparison back to the work plan reports could result in potentially insufficient monitoring of facilities. Recommendation: We recommend the agency implement procedures to ensure all monitoring visits are documented in a manner that clearly conveys all health and safety requirements were reviewed for the facility. In addition, we recommend training be provided to all monitoring staff to ensure all monitoring visits are performed in a consistent manner and are adequately documented. Further, we recommend the importance of the use of the work plan report and the retention of these real time documents be emphasized to all staff. Views of Responsible Official(s) Contact Person: Dione Smith Anticipated Completion Date: January 30th, 2023 Corrective Action Planned: The Department of Human Services agrees with the finding. Please see the corrective action plan located in the corrective action plan section of this report.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Expense and Receipt Documentation (Significant Deficiency) Information on the Federal Program: Research and Development Cluster Criteria: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, RoboNation is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the audit, we were unable to obtain supporting documentation for various expenses. Missing support included credit card receipts and approval. We were unable to verify proper account and project coding due to lack of documentation around credit cards. Context: Our audit procedures consisted of control testwork over RoboNation’s credit card cycle. We consider our sample to be representative of the population and a statistically valid sample. Cause: RoboNation did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various credit card transactions. Effect: We were unable to verify credit card expenditures in the general ledger, verify approvals, or confirm each amount in question for certain transactions. Questioned Costs: Undeterminable Identification as Repeat Finding, if Applicable: 2021-003 Recommendation: We recommend that RoboNation implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-001: Missing Supporting Documentation (Expenses) Criteria or Specific Requirement: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Although our exceptions did not disclose exceptions to Federal award documentation specifically, UHU is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Condition: During the current year audit, we had significant difficulty in obtaining supporting documentation around general expenditures, particularly vendor invoices and contracts. Although our testwork did not disclose exceptions to Federal award documentation specifically, UHU is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Context: Our audit procedures consisted of control testwork over UHU's cash disbursement cycle as well as substantive testing of Federal expenditures. Cause: UHU did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various expenditures. Effect or Potential Effect: We were unable to verify certain expenditures recorded in the general ledger, verify payee of the funds, verify terms or contract, or confirm each amount in question for certain transactions. Question Cost: Undetermined Identification as a Repeat Finding, if Applicable: Repeat of Finding 2021-001 Recommendation: We recommend UHU implement a filing system in which all supporting documentation is filed and maintained so that it can be easily accessed for future reference.
Finding 2022-002: Missing Supporting Documentation (Receipts) Criteria or Specific Requirement: Title 2 CFR 200 Section 200.333 establishes requirements of retention of financial records, supporting documents, statistical records and all other non-Federal entity records as it relates to Federal awards. Condition: During our audit, we noted several instances where backup documentation supporting certain cash receipts were not available for inspection. Although our testwork did not disclose exceptions to Federal award documentation specifically, UHU is required to maintain a system of internal controls to comply with its own record retention policy for non-Federal activity. Context: Our audit procedures consisted of substantive testwork over UHU's revenue cycle. Cause: UHU did not maintain proper systems to ensure proper filing and maintenance of documentation supporting various receipts. Effect or Potential Effect: We were unable to determine the type of income received, verify any donor mandated restrictions, or confirm the source (payer/donor) of each amount in question for certain transactions. Question Cost: Indeterminable Identification as a Repeat Finding, if Applicable: Repeat of Finding 2021-002 Recommendation: We recommend UHU implement a filing system in which all supporting documentation is filed and maintain so that it can be easily accessed for future reference.
Condition and Context: When testing the allowable costs for the Affordable Care Act Personal Responsibility Education Program for the year ended September 30, 2022, we selected a sample of 40 disbursements. Three of these 40 disbursements were credit card purchases totaling $342 for which supporting receipts could not be located, and another one of these 40 disbursements was a credit card purchase for $15 relating to another program that was misclassified as an allowable cost for the Affordable Care Act Personal Responsibility Education Program. / Criteria: All related documentation used as a basis for claiming costs under federal awards must be retained for audit in accordance with the record retention requirements contained in 2 CFR 200.333. Direct costs should be identified specifically with a particular final cost objective, such as a federal award, or with other internally or externally funded activity, or should be directly assigned to such activities relatively easily with a high degree of accuracy. / Effect: Total federal expenditures of $357 were identified as questionable costs. This may also indicate other credit card expenditures that may have been charged to federal awards that were not supported or that may have been misclassified to that federal award. / Cause: According to the management of Alternatives For Girls ("AFG"), the employee who made the credit card purchases submitted the actual receipts in hard copy to AFG's finance staff in place at the time. However, AFG's finance department had significant turnover during the year ended September 30, 2022, and the current finance department team could not locate the receipts. / Questioned Costs: Known and likely questioned costs are less than $10,000. / Recommendation: We recommend that management strengthen its processes for processing, reviewing, approving, and classifying credit card purchases, as well as maintaining documentation to support such transactions.
Condition and Context: When testing the allowable costs for the Affordable Care Act Personal Responsibility Education Program for the year ended September 30, 2022, we selected a sample of 40 disbursements. Three of these 40 disbursements were credit card purchases totaling $342 for which supporting receipts could not be located, and another one of these 40 disbursements was a credit card purchase for $15 relating to another program that was misclassified as an allowable cost for the Affordable Care Act Personal Responsibility Education Program. / Criteria: All related documentation used as a basis for claiming costs under federal awards must be retained for audit in accordance with the record retention requirements contained in 2 CFR 200.333. Direct costs should be identified specifically with a particular final cost objective, such as a federal award, or with other internally or externally funded activity, or should be directly assigned to such activities relatively easily with a high degree of accuracy. / Effect: Total federal expenditures of $357 were identified as questionable costs. This may also indicate other credit card expenditures that may have been charged to federal awards that were not supported or that may have been misclassified to that federal award. / Cause: According to the management of Alternatives For Girls ("AFG"), the employee who made the credit card purchases submitted the actual receipts in hard copy to AFG's finance staff in place at the time. However, AFG's finance department had significant turnover during the year ended September 30, 2022, and the current finance department team could not locate the receipts. / Questioned Costs: Known and likely questioned costs are less than $10,000. / Recommendation: We recommend that management strengthen its processes for processing, reviewing, approving, and classifying credit card purchases, as well as maintaining documentation to support such transactions.
Finding 2022 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Criteria: Per Uniform Guidance 2 CFR § 200.302 and 2 CFR § 200.333, entities must maintain records that adequately identify the source and application of federal funds and retain documentation to support compliance with program requirements. Condition: The Organization’s general ledger did not allow for sufficient identification of transactions related to the major program, Title V. Title V expenditures were recorded through journal entries without supporting transaction-level detail. Because of this, the population of expenditures could not be tied to individual transactions, and pulling samples from this population would not provide a reasonable basis for drawing conclusions about the population tested. As a result, we were unable to select transactions for testing or perform the necessary audit procedures to assess compliance with federal requirements. Questioned Costs: Unable to determine due to scope limitation. Cause: Staff turnover and the Organization’s recordkeeping practices did not ensure sufficient documentation was maintained to support federal compliance. Effect: Due to the lack of adequate documentation, we were unable to obtain sufficient, appropriate audit evidence to form an opinion on the Organization’s compliance with these requirements. Consequently, a disclaimed opinion on compliance was issued for this major program. Additionally, these expenditures may be subject to repayment or further review by the granting agency. Recommendation: We recommend that management strengthen documentation and recordkeeping procedures to ensure compliance with federal record retention requirements. The Organization should implement a standardized process for tracking federal grant expenditures, ensuring proper coding within the accounting system, conduct periodic internal reviews to verify completeness and accuracy of financial records, and provide training to finance staff on Uniform Guidance requirements for grant record retention and reporting. Views of Responsible Officials: See the corrective action plan that accompanies the schedule of findings and questioned costs.
Finding 2022 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Criteria: Per Uniform Guidance 2 CFR § 200.302 and 2 CFR § 200.333, entities must maintain records that adequately identify the source and application of federal funds and retain documentation to support compliance with program requirements. Condition: The Organization’s general ledger did not allow for sufficient identification of transactions related to the major program, Title V. Title V expenditures were recorded through journal entries without supporting transaction-level detail. Because of this, the population of expenditures could not be tied to individual transactions, and pulling samples from this population would not provide a reasonable basis for drawing conclusions about the population tested. As a result, we were unable to select transactions for testing or perform the necessary audit procedures to assess compliance with federal requirements. Questioned Costs: Unable to determine due to scope limitation. Cause: Staff turnover and the Organization’s recordkeeping practices did not ensure sufficient documentation was maintained to support federal compliance. Effect: Due to the lack of adequate documentation, we were unable to obtain sufficient, appropriate audit evidence to form an opinion on the Organization’s compliance with these requirements. Consequently, a disclaimed opinion on compliance was issued for this major program. Additionally, these expenditures may be subject to repayment or further review by the granting agency. Recommendation: We recommend that management strengthen documentation and recordkeeping procedures to ensure compliance with federal record retention requirements. The Organization should implement a standardized process for tracking federal grant expenditures, ensuring proper coding within the accounting system, conduct periodic internal reviews to verify completeness and accuracy of financial records, and provide training to finance staff on Uniform Guidance requirements for grant record retention and reporting. Views of Responsible Officials: See the corrective action plan that accompanies the schedule of findings and questioned costs.
Finding 2022 – 004: Procurement and Suspension and Debarment (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Criteria: Per Uniform Guidance 2 CFR § 200.302 and 2 CFR § 200.333, entities must maintain records that adequately identify the source and application of federal funds and retain documentation to support compliance with program requirements. Additionally, per 2 CFR § 200.213, entities must verify that vendors and contractors receiving federal funds are not suspended or debarred by checking the System for Award Management (SAM) or obtaining vendor certifications. Condition: The Organization was unable to provide sufficient documentation to support compliance with federal procurement and suspension and debarment requirements for purchases made under the Title V program. The general ledger did not allow for sufficient identification of transactions related to the Title V program as all expenditures were recorded through journal entries without supporting transaction-level detail. Due to this limitation, we were unable to select procurement transactions for testing or verify whether vendors had been screened for suspension and debarment before contracts were awarded. Questioned Costs: Unable to determine due to scope limitation. Cause: The Organization did not maintain adequate financial records or procurement documentation to demonstrate compliance with Uniform Guidance requirements. The lack of a complete and detailed general ledger further limited the ability to track and substantiate transactions. Finding 2022 – 004: Procurement and Suspension and Debarment (Compliance; Internal Controls Over Compliance), continued Effect: Without sufficient documentation, the Organization was unable to demonstrate compliance with federal procurement regulations, increasing the risk of noncompliance and potential disallowed costs. Additionally, these expenditures may be subject to repayment or further review by the granting agency. Recommendation: We recommend the Organization strengthen its financial recordkeeping and procurement processes by implementing procedures to ensure a complete and accurate general ledger is maintained. This should include appropriate coding to identify federal program expenditures. The Organization should also establish and enforce procurement policies that align with Uniform Guidance, including documentation of procurement methods, price or cost analyses, and vendor selection, implementing a process to verify and document vendor suspension and debarment status before awarding federally funded contracts, and conducting periodic internal reviews to ensure compliance with procurement and recordkeeping requirements. Views of Responsible Officials: See the corrective action plan that accompanies the schedule of findings and questioned costs.