Agencies: Corporation for National Community Service and U.S. Department of Health and Human Services Federal Program: All federal awards. Criteria: It is PHIMC's policy to have timecards prepared and signed by the employee and their applicable supervisor. In addition, 2 CFR 200.430 (i) Compensation-Personnel Services, Standards for Documentation of Personnel Services requires payroll systems must be based on records that accurately reflect the work performed and supported by a system of internal controls that provides reasonable assurances that charges are accurate; allowable and reasonable; and properly allocated. Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, we noted an instance in which the timesheet did not include all time worked. Context: Out of a sample of 40 timesheets, two timesheets were not complete. Sample was not statistically valid. Cause: The lack of supervisory authorizations and incomplete timesheets appear to be a result of human error and an oversight. Questions Costs: No questioned costs were identified. Effect: Amounts charged to federal awards related to these incomplete timesheets were accurate. However, lack of supervisory review and inaccurate timesheet data can lead to errors in payroll and government grant record keeping. Recommendation: We recommend PHIMC reiterate applicable policy, and ensure all timesheets are prepared, reviewed, and contain appropriate approvals. Views of Responsible Officials: Management plans to reiterate the time and effort reporting policy and ensure timesheets are completed in accordance with PHIMC policy
Agencies: Corporation for National Community Service and U.S. Department of Health and Human Services Federal Program: All federal awards. Criteria: It is PHIMC's policy to have timecards prepared and signed by the employee and their applicable supervisor. In addition, 2 CFR 200.430 (i) Compensation-Personnel Services, Standards for Documentation of Personnel Services requires payroll systems must be based on records that accurately reflect the work performed and supported by a system of internal controls that provides reasonable assurances that charges are accurate; allowable and reasonable; and properly allocated. Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, we noted an instance in which the timesheet did not include all time worked. Context: Out of a sample of 40 timesheets, two timesheets were not complete. Sample was not statistically valid. Cause: The lack of supervisory authorizations and incomplete timesheets appear to be a result of human error and an oversight. Questions Costs: No questioned costs were identified. Effect: Amounts charged to federal awards related to these incomplete timesheets were accurate. However, lack of supervisory review and inaccurate timesheet data can lead to errors in payroll and government grant record keeping. Recommendation: We recommend PHIMC reiterate applicable policy, and ensure all timesheets are prepared, reviewed, and contain appropriate approvals. Views of Responsible Officials: Management plans to reiterate the time and effort reporting policy and ensure timesheets are completed in accordance with PHIMC policy
Agencies: Corporation for National Community Service and U.S. Department of Health and Human Services Federal Program: All federal awards. Criteria: It is PHIMC's policy to have timecards prepared and signed by the employee and their applicable supervisor. In addition, 2 CFR 200.430 (i) Compensation-Personnel Services, Standards for Documentation of Personnel Services requires payroll systems must be based on records that accurately reflect the work performed and supported by a system of internal controls that provides reasonable assurances that charges are accurate; allowable and reasonable; and properly allocated. Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, we noted an instance in which the timesheet did not include all time worked. Context: Out of a sample of 40 timesheets, two timesheets were not complete. Sample was not statistically valid. Cause: The lack of supervisory authorizations and incomplete timesheets appear to be a result of human error and an oversight. Questions Costs: No questioned costs were identified. Effect: Amounts charged to federal awards related to these incomplete timesheets were accurate. However, lack of supervisory review and inaccurate timesheet data can lead to errors in payroll and government grant record keeping. Recommendation: We recommend PHIMC reiterate applicable policy, and ensure all timesheets are prepared, reviewed, and contain appropriate approvals. Views of Responsible Officials: Management plans to reiterate the time and effort reporting policy and ensure timesheets are completed in accordance with PHIMC policy
Agencies: Corporation for National Community Service and U.S. Department of Health and Human Services Federal Program: All federal awards. Criteria: It is PHIMC's policy to have timecards prepared and signed by the employee and their applicable supervisor. In addition, 2 CFR 200.430 (i) Compensation-Personnel Services, Standards for Documentation of Personnel Services requires payroll systems must be based on records that accurately reflect the work performed and supported by a system of internal controls that provides reasonable assurances that charges are accurate; allowable and reasonable; and properly allocated. Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, we noted an instance in which the timesheet did not include all time worked. Context: Out of a sample of 40 timesheets, two timesheets were not complete. Sample was not statistically valid. Cause: The lack of supervisory authorizations and incomplete timesheets appear to be a result of human error and an oversight. Questions Costs: No questioned costs were identified. Effect: Amounts charged to federal awards related to these incomplete timesheets were accurate. However, lack of supervisory review and inaccurate timesheet data can lead to errors in payroll and government grant record keeping. Recommendation: We recommend PHIMC reiterate applicable policy, and ensure all timesheets are prepared, reviewed, and contain appropriate approvals. Views of Responsible Officials: Management plans to reiterate the time and effort reporting policy and ensure timesheets are completed in accordance with PHIMC policy
Agencies: Corporation for National Community Service and U.S. Department of Health and Human Services Federal Program: All federal awards. Criteria: It is PHIMC's policy to have timecards prepared and signed by the employee and their applicable supervisor. In addition, 2 CFR 200.430 (i) Compensation-Personnel Services, Standards for Documentation of Personnel Services requires payroll systems must be based on records that accurately reflect the work performed and supported by a system of internal controls that provides reasonable assurances that charges are accurate; allowable and reasonable; and properly allocated. Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, we noted an instance in which the timesheet did not include all time worked. Context: Out of a sample of 40 timesheets, two timesheets were not complete. Sample was not statistically valid. Cause: The lack of supervisory authorizations and incomplete timesheets appear to be a result of human error and an oversight. Questions Costs: No questioned costs were identified. Effect: Amounts charged to federal awards related to these incomplete timesheets were accurate. However, lack of supervisory review and inaccurate timesheet data can lead to errors in payroll and government grant record keeping. Recommendation: We recommend PHIMC reiterate applicable policy, and ensure all timesheets are prepared, reviewed, and contain appropriate approvals. Views of Responsible Officials: Management plans to reiterate the time and effort reporting policy and ensure timesheets are completed in accordance with PHIMC policy
Agencies: Corporation for National Community Service and U.S. Department of Health and Human Services Federal Program: All federal awards. Criteria: It is PHIMC's policy to have timecards prepared and signed by the employee and their applicable supervisor. In addition, 2 CFR 200.430 (i) Compensation-Personnel Services, Standards for Documentation of Personnel Services requires payroll systems must be based on records that accurately reflect the work performed and supported by a system of internal controls that provides reasonable assurances that charges are accurate; allowable and reasonable; and properly allocated. Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, we noted an instance in which the timesheet did not include all time worked. Context: Out of a sample of 40 timesheets, two timesheets were not complete. Sample was not statistically valid. Cause: The lack of supervisory authorizations and incomplete timesheets appear to be a result of human error and an oversight. Questions Costs: No questioned costs were identified. Effect: Amounts charged to federal awards related to these incomplete timesheets were accurate. However, lack of supervisory review and inaccurate timesheet data can lead to errors in payroll and government grant record keeping. Recommendation: We recommend PHIMC reiterate applicable policy, and ensure all timesheets are prepared, reviewed, and contain appropriate approvals. Views of Responsible Officials: Management plans to reiterate the time and effort reporting policy and ensure timesheets are completed in accordance with PHIMC policy
Agencies: Corporation for National Community Service and U.S. Department of Health and Human Services Federal Program: All federal awards. Criteria: It is PHIMC's policy to have timecards prepared and signed by the employee and their applicable supervisor. In addition, 2 CFR 200.430 (i) Compensation-Personnel Services, Standards for Documentation of Personnel Services requires payroll systems must be based on records that accurately reflect the work performed and supported by a system of internal controls that provides reasonable assurances that charges are accurate; allowable and reasonable; and properly allocated. Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, we noted an instance in which the timesheet did not include all time worked. Context: Out of a sample of 40 timesheets, two timesheets were not complete. Sample was not statistically valid. Cause: The lack of supervisory authorizations and incomplete timesheets appear to be a result of human error and an oversight. Questions Costs: No questioned costs were identified. Effect: Amounts charged to federal awards related to these incomplete timesheets were accurate. However, lack of supervisory review and inaccurate timesheet data can lead to errors in payroll and government grant record keeping. Recommendation: We recommend PHIMC reiterate applicable policy, and ensure all timesheets are prepared, reviewed, and contain appropriate approvals. Views of Responsible Officials: Management plans to reiterate the time and effort reporting policy and ensure timesheets are completed in accordance with PHIMC policy
Agencies: Corporation for National Community Service and U.S. Department of Health and Human Services Federal Program: All federal awards. Criteria: It is PHIMC's policy to have timecards prepared and signed by the employee and their applicable supervisor. In addition, 2 CFR 200.430 (i) Compensation-Personnel Services, Standards for Documentation of Personnel Services requires payroll systems must be based on records that accurately reflect the work performed and supported by a system of internal controls that provides reasonable assurances that charges are accurate; allowable and reasonable; and properly allocated. Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, we noted an instance in which the timesheet did not include all time worked. Context: Out of a sample of 40 timesheets, two timesheets were not complete. Sample was not statistically valid. Cause: The lack of supervisory authorizations and incomplete timesheets appear to be a result of human error and an oversight. Questions Costs: No questioned costs were identified. Effect: Amounts charged to federal awards related to these incomplete timesheets were accurate. However, lack of supervisory review and inaccurate timesheet data can lead to errors in payroll and government grant record keeping. Recommendation: We recommend PHIMC reiterate applicable policy, and ensure all timesheets are prepared, reviewed, and contain appropriate approvals. Views of Responsible Officials: Management plans to reiterate the time and effort reporting policy and ensure timesheets are completed in accordance with PHIMC policy
Agencies: Corporation for National Community Service and U.S. Department of Health and Human Services Federal Program: All federal awards. Criteria: It is PHIMC's policy to have timecards prepared and signed by the employee and their applicable supervisor. In addition, 2 CFR 200.430 (i) Compensation-Personnel Services, Standards for Documentation of Personnel Services requires payroll systems must be based on records that accurately reflect the work performed and supported by a system of internal controls that provides reasonable assurances that charges are accurate; allowable and reasonable; and properly allocated. Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, we noted an instance in which the timesheet did not include all time worked. Context: Out of a sample of 40 timesheets, two timesheets were not complete. Sample was not statistically valid. Cause: The lack of supervisory authorizations and incomplete timesheets appear to be a result of human error and an oversight. Questions Costs: No questioned costs were identified. Effect: Amounts charged to federal awards related to these incomplete timesheets were accurate. However, lack of supervisory review and inaccurate timesheet data can lead to errors in payroll and government grant record keeping. Recommendation: We recommend PHIMC reiterate applicable policy, and ensure all timesheets are prepared, reviewed, and contain appropriate approvals. Views of Responsible Officials: Management plans to reiterate the time and effort reporting policy and ensure timesheets are completed in accordance with PHIMC policy
Agencies: Corporation for National Community Service and U.S. Department of Health and Human Services Federal Program: All federal awards. Criteria: It is PHIMC's policy to have timecards prepared and signed by the employee and their applicable supervisor. In addition, 2 CFR 200.430 (i) Compensation-Personnel Services, Standards for Documentation of Personnel Services requires payroll systems must be based on records that accurately reflect the work performed and supported by a system of internal controls that provides reasonable assurances that charges are accurate; allowable and reasonable; and properly allocated. Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, we noted an instance in which the timesheet did not include all time worked. Context: Out of a sample of 40 timesheets, two timesheets were not complete. Sample was not statistically valid. Cause: The lack of supervisory authorizations and incomplete timesheets appear to be a result of human error and an oversight. Questions Costs: No questioned costs were identified. Effect: Amounts charged to federal awards related to these incomplete timesheets were accurate. However, lack of supervisory review and inaccurate timesheet data can lead to errors in payroll and government grant record keeping. Recommendation: We recommend PHIMC reiterate applicable policy, and ensure all timesheets are prepared, reviewed, and contain appropriate approvals. Views of Responsible Officials: Management plans to reiterate the time and effort reporting policy and ensure timesheets are completed in accordance with PHIMC policy
2023-004 – Allowable Costs Relating to Time and Effort and Internal Controls Information on Federal Program(s) U.S. Department of State Name of Program: Program to End Modern Slavery Assistance Listing Number: 19.019 Grant Award Number: S-SJTIP-18-CA-1014/ S-SJTIP-18-CA-3035/S-SJTIP-20-CA-0026 Grant Award Period: October 1, 2018 through December 31, 2022; October 1, 2021 through September 30, 2024; July 1, 2022 through October 31, 2023 Criteria or Specific Requirement: In accordance with 2 CFR Section 200.430.8(i), charges to federal awards for salaries and wages must be based on records that reflect the actual work performed. The charges must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated, and must be incorporated into the official records of the non-Federal entity. Condition: For four salary transactions tested, the Fund could not provide supporting salary allocation schedules for charges made to the Federal awards. Cause: While the Fund has procedures and controls in place over payroll processing, the Fund was unable to provide the payroll cost allocation spreadsheet for two months during 2023. Effect or Potential Effect: Charges to Federal awards for salaries and wages may not reflect accurate time worked. Questioned Costs: None Context: We selected 10 salary transactions charged to the federal programs to test controls over allowable costs. For four out of 10 transactions tested, the cost allocation spreadsheet was not available for review. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Fund consistently enforce its internal controls over payroll processing and ensure that salary allocation schedules are completed and saved. View of Responsible Officials: Management agrees with the Federal award finding identified in the audit. The Fund’s response to this finding is described in the accompanying management’s corrective action plan.
2023-004 – Allowable Costs Relating to Time and Effort and Internal Controls Information on Federal Program(s) U.S. Department of State Name of Program: Program to End Modern Slavery Assistance Listing Number: 19.019 Grant Award Number: S-SJTIP-18-CA-1014/ S-SJTIP-18-CA-3035/S-SJTIP-20-CA-0026 Grant Award Period: October 1, 2018 through December 31, 2022; October 1, 2021 through September 30, 2024; July 1, 2022 through October 31, 2023 Criteria or Specific Requirement: In accordance with 2 CFR Section 200.430.8(i), charges to federal awards for salaries and wages must be based on records that reflect the actual work performed. The charges must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated, and must be incorporated into the official records of the non-Federal entity. Condition: For four salary transactions tested, the Fund could not provide supporting salary allocation schedules for charges made to the Federal awards. Cause: While the Fund has procedures and controls in place over payroll processing, the Fund was unable to provide the payroll cost allocation spreadsheet for two months during 2023. Effect or Potential Effect: Charges to Federal awards for salaries and wages may not reflect accurate time worked. Questioned Costs: None Context: We selected 10 salary transactions charged to the federal programs to test controls over allowable costs. For four out of 10 transactions tested, the cost allocation spreadsheet was not available for review. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Fund consistently enforce its internal controls over payroll processing and ensure that salary allocation schedules are completed and saved. View of Responsible Officials: Management agrees with the Federal award finding identified in the audit. The Fund’s response to this finding is described in the accompanying management’s corrective action plan.
2023-004 – Allowable Costs Relating to Time and Effort and Internal Controls Information on Federal Program(s) U.S. Department of State Name of Program: Program to End Modern Slavery Assistance Listing Number: 19.019 Grant Award Number: S-SJTIP-18-CA-1014/ S-SJTIP-18-CA-3035/S-SJTIP-20-CA-0026 Grant Award Period: October 1, 2018 through December 31, 2022; October 1, 2021 through September 30, 2024; July 1, 2022 through October 31, 2023 Criteria or Specific Requirement: In accordance with 2 CFR Section 200.430.8(i), charges to federal awards for salaries and wages must be based on records that reflect the actual work performed. The charges must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated, and must be incorporated into the official records of the non-Federal entity. Condition: For four salary transactions tested, the Fund could not provide supporting salary allocation schedules for charges made to the Federal awards. Cause: While the Fund has procedures and controls in place over payroll processing, the Fund was unable to provide the payroll cost allocation spreadsheet for two months during 2023. Effect or Potential Effect: Charges to Federal awards for salaries and wages may not reflect accurate time worked. Questioned Costs: None Context: We selected 10 salary transactions charged to the federal programs to test controls over allowable costs. For four out of 10 transactions tested, the cost allocation spreadsheet was not available for review. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Fund consistently enforce its internal controls over payroll processing and ensure that salary allocation schedules are completed and saved. View of Responsible Officials: Management agrees with the Federal award finding identified in the audit. The Fund’s response to this finding is described in the accompanying management’s corrective action plan.
Condition: The Organization does not maintain time and effort reports to support time allocations for salaried employees who are charged to the federal grant. Criteria: In accordance with 2 CFR section 200.430(g) charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. Cause: The Organization does not maintain time and effort reports to support allocations of salaried employees charged to the grant. Effect: With no time and effort reporting, the allocations for salaried employees for a particular pay period are not supported. Context: Of 25 payroll transactions tested from a population of approximately 300 transactions, we noted that payroll and related costs of $8,999 for four administrative employees were allocated to the grant, but those costs were not supported by time records or time studies. Upon further analysis of payroll costs, a total of $177,140 was determined to have been allocated to the grant for administrative employees but not supported by time records or time studies. Questioned Costs: Potential questioned costs of approximately $177,140. Recommendation: We recommend that management review controls over employee time reporting and determine an appropriate form to document time and effort for each pay period. This should include appropriate documentation of the employees time allocation between program and administrative duties based on work performed. These time and effort reports should be reviewed and approved by the employee’s direct supervisor or the Executive Director. Views of Responsible Officials and Planned Corrective Action: Management stated they will purchase a professional time tracking software program to help all employees track their work hours and activities.
Information on the Federal Program: Assistance Listing Number: 93.686—Ending the HIV Epidemic: A Plan for America—Ryan White HIV/AIDS Program Parts A and B. Pass‐Through Entity: State of Mississippi. Award Number: SG‐2199 R2. Compliance Requirements: Activities Allowed or Unallowed Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance. Criteria: As stated in 2 CFR 200.430, part g, subsection 1, line vii, “budget estimates (meaning, estimates determined before the services are performed) alone do not qualify as support for charges to Federal awards.” 2 CFR 200.430 specifies that charges must be based on records that accurately reflect the work performed. 2 CFR 200.430, part g, subsection 1, line iii further specifies that “these records must reasonably reflect the total activity for which the employee is compensated by the recipient or subrecipient, not exceeding 100 percent of compensated activities.” Condition: SEE charged personnel service cost to the contract based on budgeted estimates and did not track actual hours spent on the federally funded contract for the year ended December 31, 2023. Cause: Exempt employees need to track hours similar to non-exempt employees for federal grants. Effect or Potential Effect: As a result of the identified control deficiencies, there is a risk that personnel service costs charged to federal awards may not accurately reflect the actual work performed. This could lead to unallowable or unsupported costs being billed to federal contracts, potentially resulting in questioned costs or noncompliance with federal regulations. Questioned costs: $72,765 Recommendation: We recommend that SEE establish and implement standardized timekeeping procedures requiring all employees whose salaries are charged to federal contracts to submit accurate and complete timecards that reflect the actual hours worked. Views of responsible officials and planned corrective actions: Management acknowledges the oversight in not utilizing timecards for salaried employees whose compensation is charged to federal contracts. To strengthen internal controls and ensure compliance with applicable federal regulations, management is committed to implementing corrective measures. As part of this effort, management will update existing policies and procedures, and will identify and provide targeted training for accounting personnel responsible for allocating salary charges to federal contracts.
Finding number: 2023-006 Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Federal Program #1 HIV Emergency Relief Project Grants: CFDA Number 93.914 Federal Program #2 HIV Care Formula Grants: CFDA Number 93.917 Federal Program #2 HIV Prevention Activities: CFDA Number: 93.941 Name of federal agency: U.S. Department of Health and Human Services (HHS) AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Name of pass-through entity: Multiple Repeat finding: No Criteria: 2 CFR §200.405 requires that costs be allocable to the federal program based on relative benefits received and be supported by appropriate documentation. For personnel costs, 2 CFR §200.430(i) requires that compensation for employees whose time is charged to federal awards be based on records that accurately reflect the work performed, such as time and effort reporting or equivalent documentation. For shared costs, 2 CFR §200.412-200.414 requires that cost allocations be based on documented methodologies that are reasonable and supported by underlying calculations. Condition: The Organization does not have formalized internal controls to support the rationale for allocation of shared costs and employee time across federal programs. Specifically: Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs. Often, employees charge hours to specific programs in excess of amounts allocated to the program as expenditures. The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in the time and effort records, are determined by members of the finance staff. The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in the time and effort records, is not documented. Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained. Cause: The deficiency exists because the Organization has not implemented a structured process for documenting the extent to which allowable compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Possible effect: The absence of documented allocation methodologies in instances where allowable compensation costs exceed the amount allocated for reimbursement increases the risk that: Costs may be improperly allocated between federal programs, resulting in potential noncompliance with federal cost principles. Federal expenditures may be misstated, impacting financial and grant reporting. Although questioned costs were not identified, the lack of specific supporting documentation and controls represents a significant deficiency in internal control over compliance. Questioned cost: None identified at this time. Recommendation: We recommend that the Organization implement the following corrective actions: 1. Develop and Implement a Written Cost Allocation Policy – Establish a formal policy outlining the methodology for allocating shared costs and personnel time across programs, especially in instances where allowable costs exceed amounts allocated for reimbursement, ensuring compliance with 2 CFR Part 200 cost principles. 2. Document Allocation Methodologies for Shared Costs – Ensure that allocations for shared costs (e.g., rent, utilities, and administrative expenses) are based on a reasonable and documented methodology that can be reviewed and reperformed. 3. Retain Evidence of Implementation of Internal Controls - Implement review and approval controls over all requests for reimbursement, including review and approval of allocation of personnel and shared costs to specific funding sources. In circumstances where costs can be appropriately allocated to multiple funding sources, document the rationale for allocating the specific amount to each funding source. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Views of responsible officials: Management respectfully disagrees with this Finding. Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.
Finding number: 2023-006 Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Federal Program #1 HIV Emergency Relief Project Grants: CFDA Number 93.914 Federal Program #2 HIV Care Formula Grants: CFDA Number 93.917 Federal Program #2 HIV Prevention Activities: CFDA Number: 93.941 Name of federal agency: U.S. Department of Health and Human Services (HHS) AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Name of pass-through entity: Multiple Repeat finding: No Criteria: 2 CFR §200.405 requires that costs be allocable to the federal program based on relative benefits received and be supported by appropriate documentation. For personnel costs, 2 CFR §200.430(i) requires that compensation for employees whose time is charged to federal awards be based on records that accurately reflect the work performed, such as time and effort reporting or equivalent documentation. For shared costs, 2 CFR §200.412-200.414 requires that cost allocations be based on documented methodologies that are reasonable and supported by underlying calculations. Condition: The Organization does not have formalized internal controls to support the rationale for allocation of shared costs and employee time across federal programs. Specifically: Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs. Often, employees charge hours to specific programs in excess of amounts allocated to the program as expenditures. The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in the time and effort records, are determined by members of the finance staff. The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in the time and effort records, is not documented. Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained. Cause: The deficiency exists because the Organization has not implemented a structured process for documenting the extent to which allowable compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Possible effect: The absence of documented allocation methodologies in instances where allowable compensation costs exceed the amount allocated for reimbursement increases the risk that: Costs may be improperly allocated between federal programs, resulting in potential noncompliance with federal cost principles. Federal expenditures may be misstated, impacting financial and grant reporting. Although questioned costs were not identified, the lack of specific supporting documentation and controls represents a significant deficiency in internal control over compliance. Questioned cost: None identified at this time. Recommendation: We recommend that the Organization implement the following corrective actions: 1. Develop and Implement a Written Cost Allocation Policy – Establish a formal policy outlining the methodology for allocating shared costs and personnel time across programs, especially in instances where allowable costs exceed amounts allocated for reimbursement, ensuring compliance with 2 CFR Part 200 cost principles. 2. Document Allocation Methodologies for Shared Costs – Ensure that allocations for shared costs (e.g., rent, utilities, and administrative expenses) are based on a reasonable and documented methodology that can be reviewed and reperformed. 3. Retain Evidence of Implementation of Internal Controls - Implement review and approval controls over all requests for reimbursement, including review and approval of allocation of personnel and shared costs to specific funding sources. In circumstances where costs can be appropriately allocated to multiple funding sources, document the rationale for allocating the specific amount to each funding source. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Views of responsible officials: Management respectfully disagrees with this Finding. Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.
Finding number: 2023-006 Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Federal Program #1 HIV Emergency Relief Project Grants: CFDA Number 93.914 Federal Program #2 HIV Care Formula Grants: CFDA Number 93.917 Federal Program #2 HIV Prevention Activities: CFDA Number: 93.941 Name of federal agency: U.S. Department of Health and Human Services (HHS) AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Name of pass-through entity: Multiple Repeat finding: No Criteria: 2 CFR §200.405 requires that costs be allocable to the federal program based on relative benefits received and be supported by appropriate documentation. For personnel costs, 2 CFR §200.430(i) requires that compensation for employees whose time is charged to federal awards be based on records that accurately reflect the work performed, such as time and effort reporting or equivalent documentation. For shared costs, 2 CFR §200.412-200.414 requires that cost allocations be based on documented methodologies that are reasonable and supported by underlying calculations. Condition: The Organization does not have formalized internal controls to support the rationale for allocation of shared costs and employee time across federal programs. Specifically: Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs. Often, employees charge hours to specific programs in excess of amounts allocated to the program as expenditures. The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in the time and effort records, are determined by members of the finance staff. The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in the time and effort records, is not documented. Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained. Cause: The deficiency exists because the Organization has not implemented a structured process for documenting the extent to which allowable compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Possible effect: The absence of documented allocation methodologies in instances where allowable compensation costs exceed the amount allocated for reimbursement increases the risk that: Costs may be improperly allocated between federal programs, resulting in potential noncompliance with federal cost principles. Federal expenditures may be misstated, impacting financial and grant reporting. Although questioned costs were not identified, the lack of specific supporting documentation and controls represents a significant deficiency in internal control over compliance. Questioned cost: None identified at this time. Recommendation: We recommend that the Organization implement the following corrective actions: 1. Develop and Implement a Written Cost Allocation Policy – Establish a formal policy outlining the methodology for allocating shared costs and personnel time across programs, especially in instances where allowable costs exceed amounts allocated for reimbursement, ensuring compliance with 2 CFR Part 200 cost principles. 2. Document Allocation Methodologies for Shared Costs – Ensure that allocations for shared costs (e.g., rent, utilities, and administrative expenses) are based on a reasonable and documented methodology that can be reviewed and reperformed. 3. Retain Evidence of Implementation of Internal Controls - Implement review and approval controls over all requests for reimbursement, including review and approval of allocation of personnel and shared costs to specific funding sources. In circumstances where costs can be appropriately allocated to multiple funding sources, document the rationale for allocating the specific amount to each funding source. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Views of responsible officials: Management respectfully disagrees with this Finding. Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.
Finding number: 2023-006 Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Federal Program #1 HIV Emergency Relief Project Grants: CFDA Number 93.914 Federal Program #2 HIV Care Formula Grants: CFDA Number 93.917 Federal Program #2 HIV Prevention Activities: CFDA Number: 93.941 Name of federal agency: U.S. Department of Health and Human Services (HHS) AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Name of pass-through entity: Multiple Repeat finding: No Criteria: 2 CFR §200.405 requires that costs be allocable to the federal program based on relative benefits received and be supported by appropriate documentation. For personnel costs, 2 CFR §200.430(i) requires that compensation for employees whose time is charged to federal awards be based on records that accurately reflect the work performed, such as time and effort reporting or equivalent documentation. For shared costs, 2 CFR §200.412-200.414 requires that cost allocations be based on documented methodologies that are reasonable and supported by underlying calculations. Condition: The Organization does not have formalized internal controls to support the rationale for allocation of shared costs and employee time across federal programs. Specifically: Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs. Often, employees charge hours to specific programs in excess of amounts allocated to the program as expenditures. The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in the time and effort records, are determined by members of the finance staff. The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in the time and effort records, is not documented. Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained. Cause: The deficiency exists because the Organization has not implemented a structured process for documenting the extent to which allowable compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Possible effect: The absence of documented allocation methodologies in instances where allowable compensation costs exceed the amount allocated for reimbursement increases the risk that: Costs may be improperly allocated between federal programs, resulting in potential noncompliance with federal cost principles. Federal expenditures may be misstated, impacting financial and grant reporting. Although questioned costs were not identified, the lack of specific supporting documentation and controls represents a significant deficiency in internal control over compliance. Questioned cost: None identified at this time. Recommendation: We recommend that the Organization implement the following corrective actions: 1. Develop and Implement a Written Cost Allocation Policy – Establish a formal policy outlining the methodology for allocating shared costs and personnel time across programs, especially in instances where allowable costs exceed amounts allocated for reimbursement, ensuring compliance with 2 CFR Part 200 cost principles. 2. Document Allocation Methodologies for Shared Costs – Ensure that allocations for shared costs (e.g., rent, utilities, and administrative expenses) are based on a reasonable and documented methodology that can be reviewed and reperformed. 3. Retain Evidence of Implementation of Internal Controls - Implement review and approval controls over all requests for reimbursement, including review and approval of allocation of personnel and shared costs to specific funding sources. In circumstances where costs can be appropriately allocated to multiple funding sources, document the rationale for allocating the specific amount to each funding source. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Views of responsible officials: Management respectfully disagrees with this Finding. Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.
Finding number: 2023-006 Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Federal Program #1 HIV Emergency Relief Project Grants: CFDA Number 93.914 Federal Program #2 HIV Care Formula Grants: CFDA Number 93.917 Federal Program #2 HIV Prevention Activities: CFDA Number: 93.941 Name of federal agency: U.S. Department of Health and Human Services (HHS) AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Name of pass-through entity: Multiple Repeat finding: No Criteria: 2 CFR §200.405 requires that costs be allocable to the federal program based on relative benefits received and be supported by appropriate documentation. For personnel costs, 2 CFR §200.430(i) requires that compensation for employees whose time is charged to federal awards be based on records that accurately reflect the work performed, such as time and effort reporting or equivalent documentation. For shared costs, 2 CFR §200.412-200.414 requires that cost allocations be based on documented methodologies that are reasonable and supported by underlying calculations. Condition: The Organization does not have formalized internal controls to support the rationale for allocation of shared costs and employee time across federal programs. Specifically: Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs. Often, employees charge hours to specific programs in excess of amounts allocated to the program as expenditures. The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in the time and effort records, are determined by members of the finance staff. The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in the time and effort records, is not documented. Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained. Cause: The deficiency exists because the Organization has not implemented a structured process for documenting the extent to which allowable compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Possible effect: The absence of documented allocation methodologies in instances where allowable compensation costs exceed the amount allocated for reimbursement increases the risk that: Costs may be improperly allocated between federal programs, resulting in potential noncompliance with federal cost principles. Federal expenditures may be misstated, impacting financial and grant reporting. Although questioned costs were not identified, the lack of specific supporting documentation and controls represents a significant deficiency in internal control over compliance. Questioned cost: None identified at this time. Recommendation: We recommend that the Organization implement the following corrective actions: 1. Develop and Implement a Written Cost Allocation Policy – Establish a formal policy outlining the methodology for allocating shared costs and personnel time across programs, especially in instances where allowable costs exceed amounts allocated for reimbursement, ensuring compliance with 2 CFR Part 200 cost principles. 2. Document Allocation Methodologies for Shared Costs – Ensure that allocations for shared costs (e.g., rent, utilities, and administrative expenses) are based on a reasonable and documented methodology that can be reviewed and reperformed. 3. Retain Evidence of Implementation of Internal Controls - Implement review and approval controls over all requests for reimbursement, including review and approval of allocation of personnel and shared costs to specific funding sources. In circumstances where costs can be appropriately allocated to multiple funding sources, document the rationale for allocating the specific amount to each funding source. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Views of responsible officials: Management respectfully disagrees with this Finding. Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.
Finding number: 2023-006 Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Federal Program #1 HIV Emergency Relief Project Grants: CFDA Number 93.914 Federal Program #2 HIV Care Formula Grants: CFDA Number 93.917 Federal Program #2 HIV Prevention Activities: CFDA Number: 93.941 Name of federal agency: U.S. Department of Health and Human Services (HHS) AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Name of pass-through entity: Multiple Repeat finding: No Criteria: 2 CFR §200.405 requires that costs be allocable to the federal program based on relative benefits received and be supported by appropriate documentation. For personnel costs, 2 CFR §200.430(i) requires that compensation for employees whose time is charged to federal awards be based on records that accurately reflect the work performed, such as time and effort reporting or equivalent documentation. For shared costs, 2 CFR §200.412-200.414 requires that cost allocations be based on documented methodologies that are reasonable and supported by underlying calculations. Condition: The Organization does not have formalized internal controls to support the rationale for allocation of shared costs and employee time across federal programs. Specifically: Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs. Often, employees charge hours to specific programs in excess of amounts allocated to the program as expenditures. The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in the time and effort records, are determined by members of the finance staff. The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in the time and effort records, is not documented. Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained. Cause: The deficiency exists because the Organization has not implemented a structured process for documenting the extent to which allowable compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Possible effect: The absence of documented allocation methodologies in instances where allowable compensation costs exceed the amount allocated for reimbursement increases the risk that: Costs may be improperly allocated between federal programs, resulting in potential noncompliance with federal cost principles. Federal expenditures may be misstated, impacting financial and grant reporting. Although questioned costs were not identified, the lack of specific supporting documentation and controls represents a significant deficiency in internal control over compliance. Questioned cost: None identified at this time. Recommendation: We recommend that the Organization implement the following corrective actions: 1. Develop and Implement a Written Cost Allocation Policy – Establish a formal policy outlining the methodology for allocating shared costs and personnel time across programs, especially in instances where allowable costs exceed amounts allocated for reimbursement, ensuring compliance with 2 CFR Part 200 cost principles. 2. Document Allocation Methodologies for Shared Costs – Ensure that allocations for shared costs (e.g., rent, utilities, and administrative expenses) are based on a reasonable and documented methodology that can be reviewed and reperformed. 3. Retain Evidence of Implementation of Internal Controls - Implement review and approval controls over all requests for reimbursement, including review and approval of allocation of personnel and shared costs to specific funding sources. In circumstances where costs can be appropriately allocated to multiple funding sources, document the rationale for allocating the specific amount to each funding source. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Views of responsible officials: Management respectfully disagrees with this Finding. Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.
Finding number: 2023-006 Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Federal Program #1 HIV Emergency Relief Project Grants: CFDA Number 93.914 Federal Program #2 HIV Care Formula Grants: CFDA Number 93.917 Federal Program #2 HIV Prevention Activities: CFDA Number: 93.941 Name of federal agency: U.S. Department of Health and Human Services (HHS) AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Name of pass-through entity: Multiple Repeat finding: No Criteria: 2 CFR §200.405 requires that costs be allocable to the federal program based on relative benefits received and be supported by appropriate documentation. For personnel costs, 2 CFR §200.430(i) requires that compensation for employees whose time is charged to federal awards be based on records that accurately reflect the work performed, such as time and effort reporting or equivalent documentation. For shared costs, 2 CFR §200.412-200.414 requires that cost allocations be based on documented methodologies that are reasonable and supported by underlying calculations. Condition: The Organization does not have formalized internal controls to support the rationale for allocation of shared costs and employee time across federal programs. Specifically: Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs. Often, employees charge hours to specific programs in excess of amounts allocated to the program as expenditures. The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in the time and effort records, are determined by members of the finance staff. The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in the time and effort records, is not documented. Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained. Cause: The deficiency exists because the Organization has not implemented a structured process for documenting the extent to which allowable compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Possible effect: The absence of documented allocation methodologies in instances where allowable compensation costs exceed the amount allocated for reimbursement increases the risk that: Costs may be improperly allocated between federal programs, resulting in potential noncompliance with federal cost principles. Federal expenditures may be misstated, impacting financial and grant reporting. Although questioned costs were not identified, the lack of specific supporting documentation and controls represents a significant deficiency in internal control over compliance. Questioned cost: None identified at this time. Recommendation: We recommend that the Organization implement the following corrective actions: 1. Develop and Implement a Written Cost Allocation Policy – Establish a formal policy outlining the methodology for allocating shared costs and personnel time across programs, especially in instances where allowable costs exceed amounts allocated for reimbursement, ensuring compliance with 2 CFR Part 200 cost principles. 2. Document Allocation Methodologies for Shared Costs – Ensure that allocations for shared costs (e.g., rent, utilities, and administrative expenses) are based on a reasonable and documented methodology that can be reviewed and reperformed. 3. Retain Evidence of Implementation of Internal Controls - Implement review and approval controls over all requests for reimbursement, including review and approval of allocation of personnel and shared costs to specific funding sources. In circumstances where costs can be appropriately allocated to multiple funding sources, document the rationale for allocating the specific amount to each funding source. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Views of responsible officials: Management respectfully disagrees with this Finding. Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.
Finding number: 2023-006 Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Federal Program #1 HIV Emergency Relief Project Grants: CFDA Number 93.914 Federal Program #2 HIV Care Formula Grants: CFDA Number 93.917 Federal Program #2 HIV Prevention Activities: CFDA Number: 93.941 Name of federal agency: U.S. Department of Health and Human Services (HHS) AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Name of pass-through entity: Multiple Repeat finding: No Criteria: 2 CFR §200.405 requires that costs be allocable to the federal program based on relative benefits received and be supported by appropriate documentation. For personnel costs, 2 CFR §200.430(i) requires that compensation for employees whose time is charged to federal awards be based on records that accurately reflect the work performed, such as time and effort reporting or equivalent documentation. For shared costs, 2 CFR §200.412-200.414 requires that cost allocations be based on documented methodologies that are reasonable and supported by underlying calculations. Condition: The Organization does not have formalized internal controls to support the rationale for allocation of shared costs and employee time across federal programs. Specifically: Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs. Often, employees charge hours to specific programs in excess of amounts allocated to the program as expenditures. The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in the time and effort records, are determined by members of the finance staff. The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in the time and effort records, is not documented. Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained. Cause: The deficiency exists because the Organization has not implemented a structured process for documenting the extent to which allowable compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Possible effect: The absence of documented allocation methodologies in instances where allowable compensation costs exceed the amount allocated for reimbursement increases the risk that: Costs may be improperly allocated between federal programs, resulting in potential noncompliance with federal cost principles. Federal expenditures may be misstated, impacting financial and grant reporting. Although questioned costs were not identified, the lack of specific supporting documentation and controls represents a significant deficiency in internal control over compliance. Questioned cost: None identified at this time. Recommendation: We recommend that the Organization implement the following corrective actions: 1. Develop and Implement a Written Cost Allocation Policy – Establish a formal policy outlining the methodology for allocating shared costs and personnel time across programs, especially in instances where allowable costs exceed amounts allocated for reimbursement, ensuring compliance with 2 CFR Part 200 cost principles. 2. Document Allocation Methodologies for Shared Costs – Ensure that allocations for shared costs (e.g., rent, utilities, and administrative expenses) are based on a reasonable and documented methodology that can be reviewed and reperformed. 3. Retain Evidence of Implementation of Internal Controls - Implement review and approval controls over all requests for reimbursement, including review and approval of allocation of personnel and shared costs to specific funding sources. In circumstances where costs can be appropriately allocated to multiple funding sources, document the rationale for allocating the specific amount to each funding source. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Views of responsible officials: Management respectfully disagrees with this Finding. Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.
Finding number: 2023-006 Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Federal Program #1 HIV Emergency Relief Project Grants: CFDA Number 93.914 Federal Program #2 HIV Care Formula Grants: CFDA Number 93.917 Federal Program #2 HIV Prevention Activities: CFDA Number: 93.941 Name of federal agency: U.S. Department of Health and Human Services (HHS) AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Name of pass-through entity: Multiple Repeat finding: No Criteria: 2 CFR §200.405 requires that costs be allocable to the federal program based on relative benefits received and be supported by appropriate documentation. For personnel costs, 2 CFR §200.430(i) requires that compensation for employees whose time is charged to federal awards be based on records that accurately reflect the work performed, such as time and effort reporting or equivalent documentation. For shared costs, 2 CFR §200.412-200.414 requires that cost allocations be based on documented methodologies that are reasonable and supported by underlying calculations. Condition: The Organization does not have formalized internal controls to support the rationale for allocation of shared costs and employee time across federal programs. Specifically: Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs. Often, employees charge hours to specific programs in excess of amounts allocated to the program as expenditures. The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in the time and effort records, are determined by members of the finance staff. The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in the time and effort records, is not documented. Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained. Cause: The deficiency exists because the Organization has not implemented a structured process for documenting the extent to which allowable compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Possible effect: The absence of documented allocation methodologies in instances where allowable compensation costs exceed the amount allocated for reimbursement increases the risk that: Costs may be improperly allocated between federal programs, resulting in potential noncompliance with federal cost principles. Federal expenditures may be misstated, impacting financial and grant reporting. Although questioned costs were not identified, the lack of specific supporting documentation and controls represents a significant deficiency in internal control over compliance. Questioned cost: None identified at this time. Recommendation: We recommend that the Organization implement the following corrective actions: 1. Develop and Implement a Written Cost Allocation Policy – Establish a formal policy outlining the methodology for allocating shared costs and personnel time across programs, especially in instances where allowable costs exceed amounts allocated for reimbursement, ensuring compliance with 2 CFR Part 200 cost principles. 2. Document Allocation Methodologies for Shared Costs – Ensure that allocations for shared costs (e.g., rent, utilities, and administrative expenses) are based on a reasonable and documented methodology that can be reviewed and reperformed. 3. Retain Evidence of Implementation of Internal Controls - Implement review and approval controls over all requests for reimbursement, including review and approval of allocation of personnel and shared costs to specific funding sources. In circumstances where costs can be appropriately allocated to multiple funding sources, document the rationale for allocating the specific amount to each funding source. AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) Views of responsible officials: Management respectfully disagrees with this Finding. Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a AIDS Arms, Inc. dba Prism Health North Texas and Subsidiary Schedule of Findings and Questioned Costs For the Year Ended December 31, 2023 SECTION III - SUMMARY OF FEDERAL AWARD FINDINGS AND QUESTIONED COSTS (continued) process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.
Finding 2023-002: Internal Controls over Allowable Costs Federal Department: U.S. Department of Education Pass-through Agencies: State of South Carolina Department of Education, Minnesota Department of Education, and DC Office of the State Superintendent of Education Federal Program Name: Twenty-First Century Community Learning Centers Assistance Listing Number: 84.287 Type of Finding: Significant Deficiency in Internal Control over Compliance Other Matters Criteria 2 CFR Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart D – Post-Federal Award Requirements Standards Section 200.303, Internal controls states “The non-Federal” entity must: (1) establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and conditions of the Federal award. Section 200.430 (i) Standards for Documentation of Personnel Expenses states (1) Charges to federal awards for salaries and wages 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; (ii) Be incorporated into the official records of the non-federal entity; (iii) Reasonably reflect the total activity for which the employee is compensated by the non-federal entity, not exceeding 100% of compensated activities…; (v) Comply with the established accounting policies and practices of the non-federal entity…; (viii) Budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to federal awards, but may be used for interim accounting purposes, provided that: (A) The system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) Significant changes in the corresponding work activity (as defined by the non-federal entity's written policies) are identified and entered into the records in a timely manner. Short-term (such as one or two months) fluctuation between workload categories need not be considered as long as the distribution of salaries and wages is reasonable over the longer term; and (C) The non-federal entity's system of internal controls includes processes to review after-the-fact interim charges made to a federal award based on budget estimates. All necessary adjustments must be made such that the final amount charged to the federal award is accurate, allowable, and properly allocated. Condition/Context During the current audit period, CDF did not maintain adequate control over allowable costs related to its federally funded program. Exceptions were noted in 21 of 60 tested payroll expenditures: For 16 payroll expenditures, we were not provided with any evidence of approval of allocations. We noted these allocations were based on budget estimates, instead of actual time and effort reporting. For five payroll expenditures tested, we were not provided with any supporting documentation to determine if the expenditures were allowable. Exceptions were noted in nine of 60 non-payroll expenditures tested: For six non-payroll expenditures tested, we were not provided with any evidence of approval of the overhead allocations. We reviewed the supporting documentation, and the expenditures are deemed allowable. For three non-payroll expenditures tested, we were not provided with any supporting documentation to determine if the expenditure was allowable. Cause Based on our discussions with management, this finding occurred due to staff turnover. As a result, consistent documentation was not maintained to support the approval of expenditure allocations. Effect The failure to maintain adequate documentation to verify that expenditures are properly reviewed and approved and to maintain adequate supporting documentation to ensure all payroll and non-payroll expenditures are reasonable and properly reviewed is a violation of federal regulations, which could result in unallowed costs being charged to the federally funded program. Questioned Costs $42,119 Identification of Repeat Findings Repeated (Prior Finding No. 2022-001). Recommendation We recommend that CDF implement procedures to ensure all expenditure allocations are properly reviewed and approved and supporting documentation is maintained in accordance with federal regulations. Views of Responsible Officials and Corrective Action Plan CDF agrees with the finding and recommendation. See CDF’s Corrective Action Plan on pages 18-20.
Finding 2023-002: Internal Controls over Allowable Costs Federal Department: U.S. Department of Education Pass-through Agencies: State of South Carolina Department of Education, Minnesota Department of Education, and DC Office of the State Superintendent of Education Federal Program Name: Twenty-First Century Community Learning Centers Assistance Listing Number: 84.287 Type of Finding: Significant Deficiency in Internal Control over Compliance Other Matters Criteria 2 CFR Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart D – Post-Federal Award Requirements Standards Section 200.303, Internal controls states “The non-Federal” entity must: (1) establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and conditions of the Federal award. Section 200.430 (i) Standards for Documentation of Personnel Expenses states (1) Charges to federal awards for salaries and wages 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; (ii) Be incorporated into the official records of the non-federal entity; (iii) Reasonably reflect the total activity for which the employee is compensated by the non-federal entity, not exceeding 100% of compensated activities…; (v) Comply with the established accounting policies and practices of the non-federal entity…; (viii) Budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to federal awards, but may be used for interim accounting purposes, provided that: (A) The system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) Significant changes in the corresponding work activity (as defined by the non-federal entity's written policies) are identified and entered into the records in a timely manner. Short-term (such as one or two months) fluctuation between workload categories need not be considered as long as the distribution of salaries and wages is reasonable over the longer term; and (C) The non-federal entity's system of internal controls includes processes to review after-the-fact interim charges made to a federal award based on budget estimates. All necessary adjustments must be made such that the final amount charged to the federal award is accurate, allowable, and properly allocated. Condition/Context During the current audit period, CDF did not maintain adequate control over allowable costs related to its federally funded program. Exceptions were noted in 21 of 60 tested payroll expenditures: For 16 payroll expenditures, we were not provided with any evidence of approval of allocations. We noted these allocations were based on budget estimates, instead of actual time and effort reporting. For five payroll expenditures tested, we were not provided with any supporting documentation to determine if the expenditures were allowable. Exceptions were noted in nine of 60 non-payroll expenditures tested: For six non-payroll expenditures tested, we were not provided with any evidence of approval of the overhead allocations. We reviewed the supporting documentation, and the expenditures are deemed allowable. For three non-payroll expenditures tested, we were not provided with any supporting documentation to determine if the expenditure was allowable. Cause Based on our discussions with management, this finding occurred due to staff turnover. As a result, consistent documentation was not maintained to support the approval of expenditure allocations. Effect The failure to maintain adequate documentation to verify that expenditures are properly reviewed and approved and to maintain adequate supporting documentation to ensure all payroll and non-payroll expenditures are reasonable and properly reviewed is a violation of federal regulations, which could result in unallowed costs being charged to the federally funded program. Questioned Costs $42,119 Identification of Repeat Findings Repeated (Prior Finding No. 2022-001). Recommendation We recommend that CDF implement procedures to ensure all expenditure allocations are properly reviewed and approved and supporting documentation is maintained in accordance with federal regulations. Views of Responsible Officials and Corrective Action Plan CDF agrees with the finding and recommendation. See CDF’s Corrective Action Plan on pages 18-20.
Finding 2023-002: Internal Controls over Allowable Costs Federal Department: U.S. Department of Education Pass-through Agencies: State of South Carolina Department of Education, Minnesota Department of Education, and DC Office of the State Superintendent of Education Federal Program Name: Twenty-First Century Community Learning Centers Assistance Listing Number: 84.287 Type of Finding: Significant Deficiency in Internal Control over Compliance Other Matters Criteria 2 CFR Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart D – Post-Federal Award Requirements Standards Section 200.303, Internal controls states “The non-Federal” entity must: (1) establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and conditions of the Federal award. Section 200.430 (i) Standards for Documentation of Personnel Expenses states (1) Charges to federal awards for salaries and wages 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; (ii) Be incorporated into the official records of the non-federal entity; (iii) Reasonably reflect the total activity for which the employee is compensated by the non-federal entity, not exceeding 100% of compensated activities…; (v) Comply with the established accounting policies and practices of the non-federal entity…; (viii) Budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to federal awards, but may be used for interim accounting purposes, provided that: (A) The system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) Significant changes in the corresponding work activity (as defined by the non-federal entity's written policies) are identified and entered into the records in a timely manner. Short-term (such as one or two months) fluctuation between workload categories need not be considered as long as the distribution of salaries and wages is reasonable over the longer term; and (C) The non-federal entity's system of internal controls includes processes to review after-the-fact interim charges made to a federal award based on budget estimates. All necessary adjustments must be made such that the final amount charged to the federal award is accurate, allowable, and properly allocated. Condition/Context During the current audit period, CDF did not maintain adequate control over allowable costs related to its federally funded program. Exceptions were noted in 21 of 60 tested payroll expenditures: For 16 payroll expenditures, we were not provided with any evidence of approval of allocations. We noted these allocations were based on budget estimates, instead of actual time and effort reporting. For five payroll expenditures tested, we were not provided with any supporting documentation to determine if the expenditures were allowable. Exceptions were noted in nine of 60 non-payroll expenditures tested: For six non-payroll expenditures tested, we were not provided with any evidence of approval of the overhead allocations. We reviewed the supporting documentation, and the expenditures are deemed allowable. For three non-payroll expenditures tested, we were not provided with any supporting documentation to determine if the expenditure was allowable. Cause Based on our discussions with management, this finding occurred due to staff turnover. As a result, consistent documentation was not maintained to support the approval of expenditure allocations. Effect The failure to maintain adequate documentation to verify that expenditures are properly reviewed and approved and to maintain adequate supporting documentation to ensure all payroll and non-payroll expenditures are reasonable and properly reviewed is a violation of federal regulations, which could result in unallowed costs being charged to the federally funded program. Questioned Costs $42,119 Identification of Repeat Findings Repeated (Prior Finding No. 2022-001). Recommendation We recommend that CDF implement procedures to ensure all expenditure allocations are properly reviewed and approved and supporting documentation is maintained in accordance with federal regulations. Views of Responsible Officials and Corrective Action Plan CDF agrees with the finding and recommendation. See CDF’s Corrective Action Plan on pages 18-20.
Payroll Allocations and Contract Allocations Finding Number: 2023-005 Assistance Listing Number and Title: AL # 14.871 - Section 8 Housing Choice Vouchers/Housing Voucher Cluster Federal Award Identification Number / Year: 2023 Federal Agency: U.S. Department of Housing and Urban Development Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Pass-Through Entity: N/A Repeat Finding from Prior Audit? Yes Prior Audit Finding Number: 2022-007 Noncompliance and Material Weakness 2 CFR § 2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR Part 200 Subpart E § 200.403 which provides that, except where otherwise authorized by statute, costs must meet certain general criteria in order to be allowable under Federal awards including being necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles and being adequately documented. 2 C.F.R. § 200.430 provides, in part, that costs of compensation are allowable to the extent that they satisfy the specific requirements of this part, and that the total compensation for individual employees is reasonable for the services rendered and conforms to the established written policy of the non-Federal entity consistently applied to both Federal and non-Federal activities. The Authority utilizes a standard allocation of 85% to serve as a cost allocation plan for consultant contracts to the Housing Choice Voucher (HCV) Program. However, the percentages in the plan are not updated annually and the plan does not specify which expenses are subject to the allocation percentage. Further, the Authority was unable to provide supporting documentation for the allocation percentages in the plan. As such, during 2023, the Authority charged $9,068 to the Housing Voucher Cluster in excess of supported amounts. In addition, the Authority approved a standard allocation of 59% for employee benefits charged to the Housing Choice Voucher (HCV) Program. However, the Authority charged 85% of certain benefits for employees during 2023 resulting in $2,080 charged to the Housing Voucher Cluster in excess of supported amounts. The failure to update and support percentages used to allocate federal expenditures to ensure they are reasonable based on current activity could result in findings for adjustment or questioned costs in the federal programs. During 2023, the total unsupported charges totaled $11,148. The Authority should update the percentages used in its cost allocation plan. Further, the Authority should update its plan to identify which expenses are subject to allocation by this plan. In addition, the Authority should utilize only approved and supported percentages for allocation of federal expenditures.
Payroll Allocations and Contract Allocations Finding Number: 2023-005 Assistance Listing Number and Title: AL # 14.871 - Section 8 Housing Choice Vouchers/Housing Voucher Cluster Federal Award Identification Number / Year: 2023 Federal Agency: U.S. Department of Housing and Urban Development Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Pass-Through Entity: N/A Repeat Finding from Prior Audit? Yes Prior Audit Finding Number: 2022-007 Noncompliance and Material Weakness 2 CFR § 2400.101 gives regulatory effect to the Department of Housing and Urban Development for 2 CFR Part 200 Subpart E § 200.403 which provides that, except where otherwise authorized by statute, costs must meet certain general criteria in order to be allowable under Federal awards including being necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles and being adequately documented. 2 C.F.R. § 200.430 provides, in part, that costs of compensation are allowable to the extent that they satisfy the specific requirements of this part, and that the total compensation for individual employees is reasonable for the services rendered and conforms to the established written policy of the non-Federal entity consistently applied to both Federal and non-Federal activities. The Authority utilizes a standard allocation of 85% to serve as a cost allocation plan for consultant contracts to the Housing Choice Voucher (HCV) Program. However, the percentages in the plan are not updated annually and the plan does not specify which expenses are subject to the allocation percentage. Further, the Authority was unable to provide supporting documentation for the allocation percentages in the plan. As such, during 2023, the Authority charged $9,068 to the Housing Voucher Cluster in excess of supported amounts. In addition, the Authority approved a standard allocation of 59% for employee benefits charged to the Housing Choice Voucher (HCV) Program. However, the Authority charged 85% of certain benefits for employees during 2023 resulting in $2,080 charged to the Housing Voucher Cluster in excess of supported amounts. The failure to update and support percentages used to allocate federal expenditures to ensure they are reasonable based on current activity could result in findings for adjustment or questioned costs in the federal programs. During 2023, the total unsupported charges totaled $11,148. The Authority should update the percentages used in its cost allocation plan. Further, the Authority should update its plan to identify which expenses are subject to allocation by this plan. In addition, the Authority should utilize only approved and supported percentages for allocation of federal expenditures.
U. S. Department of Health and Human Services 2023-002 Allowable Costs Program(s) Name of Federal Program (Assistance Listing Number) Urban Indian Health Services (93.193) Special Diabetes Program for Indians - Diabetes Prevention and Treatment Projects (93.237) Criteria - Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non-Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services for the programs identified above. Context and Condition - We selected 29 paychecks from several pay periods to test for compliance with standards in these two programs. Records for five of the paychecks tested lacked documentation of approval of the employee’s supervisor. Cause - The Organization replaced its payroll processing servicer subsequent to 2023. Access to certain records from the prior servicer were no longer available. Personnel turnover resulting in inconsistencies in maintaining required documentation. Effect - A federal program could be charged compensation for employees who did not provide services directly attributable to the program or charged for goods/services not related to the program. Questioned Costs - No costs were questioned. Repeat finding - Yes Statistically valid - Yes Recommendation - We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job-costing system implemented. Views of responsible officials - The Organization believes the paychecks identified were approved prior to payment. We will ensure that documentation is downloaded each pay period to ensure such documentation is not lost when a change in servicer is made.
U. S. Department of Health and Human Services 2023-002 Allowable Costs Program(s) Name of Federal Program (Assistance Listing Number) Urban Indian Health Services (93.193) Special Diabetes Program for Indians - Diabetes Prevention and Treatment Projects (93.237) Criteria - Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non-Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services for the programs identified above. Context and Condition - We selected 29 paychecks from several pay periods to test for compliance with standards in these two programs. Records for five of the paychecks tested lacked documentation of approval of the employee’s supervisor. Cause - The Organization replaced its payroll processing servicer subsequent to 2023. Access to certain records from the prior servicer were no longer available. Personnel turnover resulting in inconsistencies in maintaining required documentation. Effect - A federal program could be charged compensation for employees who did not provide services directly attributable to the program or charged for goods/services not related to the program. Questioned Costs - No costs were questioned. Repeat finding - Yes Statistically valid - Yes Recommendation - We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job-costing system implemented. Views of responsible officials - The Organization believes the paychecks identified were approved prior to payment. We will ensure that documentation is downloaded each pay period to ensure such documentation is not lost when a change in servicer is made.
Finding No.2023-003: Improve Controls Over Expense Reporting and Payroll Charges Assistance Listing Number: 93.566 Assistance Listing Program Title: Refugee and Entrant Assistance – State - Administered Programs Federal Agency: Department of Health and Human Services (HHS) Passed Through Entity: 1. San Diego Refugee Communities Coalition/United Women of East Africa Support Team 2. California Department of Social Services (CDSS) Federal Award Number: 1. Not available in the contract 2. ACS22-05-CAIR-A1 Federal Award Year: 1. February 1, 2023 – March 31, 2024 2. November 1, 2022 – March 31, 2025 Compliance Requirement: Allowable Costs/Cost Principles Criteria or Specific Requirements: In accordance with 2 CFR 200.403 and 200.405, costs charged to a federal award must be necessary, reasonable, and allocable. In addition, 2 CFR 200.430 Compensation-personal services, provides that compensation for personal services must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Condition: During our testing of 21 non-payroll expenses, we identified one instance wherein translation services amounting to $795, provided by a staff member, were charged under professional fees, even though the individual's salary was recorded and billed under salary expenses. Additionally, in our testing of 25 payroll expenses, we identified one instance of overbilling in the amount $622. This occurred because the payroll charge was based on budgeted Full Time Equivalents (FTEs) rather than the actual time worked. Cause: CAIR-CA's current internal controls for reviewing billings under the federal program were not sufficient to consistently prevent or detect duplicate or inaccurate charges. Furthermore, CAIR-CA lacked adequate internal controls to ensure that payroll allocations were based on actual time worked on the federal program. Effect: These control deficiencies resulted in the overbilling of federal funds. Questioned Cost: $1,417 Recommendation: To ensure compliance with the Uniform Guidance, we recommend that CAIR-CA strengthen its internal controls over expense reporting by implementing enhanced review procedures to verify the allowability of costs charged to federal awards. Additionally, CAIR-CA should establish formal procedures to ensure that payroll charges to federal programs are based on actual time and effort records. Management should conduct regular reviews and make necessary adjustments to payroll allocations to accurately reflect the work performed on federally funded activities. Views of Responsible Officials and Corrective Action Plan: Management concurs with the finding and has already initiated enhancements to its review process to ensure that expense reports are consistently reviewed and approved by both supervisors and finance personnel prior to being charged to federal awards. These steps are designed to further strengthen internal controls and support compliance with federal requirements. In addition, Finance staff are formalizing procedures to reconcile payroll charges on a regular basis to ensure compliance with federal requirements and to confirm that all charges to federal programs are supported by actual time and effort records. Responsible person: Jackie Ramirez, Operations & Finance Associate Director Expected Implementation date: October 31, 2025
Finding No.2023-003: Improve Controls Over Expense Reporting and Payroll Charges Assistance Listing Number: 93.566 Assistance Listing Program Title: Refugee and Entrant Assistance – State - Administered Programs Federal Agency: Department of Health and Human Services (HHS) Passed Through Entity: 1. San Diego Refugee Communities Coalition/United Women of East Africa Support Team 2. California Department of Social Services (CDSS) Federal Award Number: 1. Not available in the contract 2. ACS22-05-CAIR-A1 Federal Award Year: 1. February 1, 2023 – March 31, 2024 2. November 1, 2022 – March 31, 2025 Compliance Requirement: Allowable Costs/Cost Principles Criteria or Specific Requirements: In accordance with 2 CFR 200.403 and 200.405, costs charged to a federal award must be necessary, reasonable, and allocable. In addition, 2 CFR 200.430 Compensation-personal services, provides that compensation for personal services must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Condition: During our testing of 21 non-payroll expenses, we identified one instance wherein translation services amounting to $795, provided by a staff member, were charged under professional fees, even though the individual's salary was recorded and billed under salary expenses. Additionally, in our testing of 25 payroll expenses, we identified one instance of overbilling in the amount $622. This occurred because the payroll charge was based on budgeted Full Time Equivalents (FTEs) rather than the actual time worked. Cause: CAIR-CA's current internal controls for reviewing billings under the federal program were not sufficient to consistently prevent or detect duplicate or inaccurate charges. Furthermore, CAIR-CA lacked adequate internal controls to ensure that payroll allocations were based on actual time worked on the federal program. Effect: These control deficiencies resulted in the overbilling of federal funds. Questioned Cost: $1,417 Recommendation: To ensure compliance with the Uniform Guidance, we recommend that CAIR-CA strengthen its internal controls over expense reporting by implementing enhanced review procedures to verify the allowability of costs charged to federal awards. Additionally, CAIR-CA should establish formal procedures to ensure that payroll charges to federal programs are based on actual time and effort records. Management should conduct regular reviews and make necessary adjustments to payroll allocations to accurately reflect the work performed on federally funded activities. Views of Responsible Officials and Corrective Action Plan: Management concurs with the finding and has already initiated enhancements to its review process to ensure that expense reports are consistently reviewed and approved by both supervisors and finance personnel prior to being charged to federal awards. These steps are designed to further strengthen internal controls and support compliance with federal requirements. In addition, Finance staff are formalizing procedures to reconcile payroll charges on a regular basis to ensure compliance with federal requirements and to confirm that all charges to federal programs are supported by actual time and effort records. Responsible person: Jackie Ramirez, Operations & Finance Associate Director Expected Implementation date: October 31, 2025
2 CFR 200 outlines the following policies required for a County spending Coronavirus State and Local Fiscal Recovery Funds: • 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles; • 2 CFR 200.430 for allowability of compensation costs; 2 CFR 200.464(a)(2) for reimbursement of relocation costs; • 2 CFR 200.318(c)(1) for employee conflicts of interest; • 2 CFR 200.318(c)(2) for organizational conflicts of interest; • 2 CFR 200.320(b)(2) for selection and awarding of contracts for competitive proposals; • 2 CFR 200.319(d) for minimum evaluation criteria for bids and proposals. During testing we noted that the County did not have sufficient written policies addressing the above requirements. Failure to adopt and implement policies could lead to noncompliance with federal requirements. We recommend the County approve and implement the above policies to ensure compliance with federal requirements.
2 CFR 200 outlines the following policies required for a County spending Coronavirus State and Local Fiscal Recovery Funds: • 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles; • 2 CFR 200.430 for allowability of compensation costs; 2 CFR 200.464(a)(2) for reimbursement of relocation costs; • 2 CFR 200.318(c)(1) for employee conflicts of interest; • 2 CFR 200.318(c)(2) for organizational conflicts of interest; • 2 CFR 200.320(b)(2) for selection and awarding of contracts for competitive proposals; • 2 CFR 200.319(d) for minimum evaluation criteria for bids and proposals. During testing we noted that the County did not have sufficient written policies addressing the above requirements. Failure to adopt and implement policies could lead to noncompliance with federal requirements. We recommend the County approve and implement the above policies to ensure compliance with federal requirements.
2 CFR 200 outlines the following policies required for a County spending Coronavirus State and Local Fiscal Recovery Funds: • 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles; • 2 CFR 200.430 for allowability of compensation costs; 2 CFR 200.464(a)(2) for reimbursement of relocation costs; • 2 CFR 200.318(c)(1) for employee conflicts of interest; • 2 CFR 200.318(c)(2) for organizational conflicts of interest; • 2 CFR 200.320(b)(2) for selection and awarding of contracts for competitive proposals; • 2 CFR 200.319(d) for minimum evaluation criteria for bids and proposals. During testing we noted that the County did not have sufficient written policies addressing the above requirements. Failure to adopt and implement policies could lead to noncompliance with federal requirements. We recommend the County approve and implement the above policies to ensure compliance with federal requirements.
2 CFR 200 outlines the following policies required for a County spending Coronavirus State and Local Fiscal Recovery Funds: • 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles; • 2 CFR 200.430 for allowability of compensation costs; 2 CFR 200.464(a)(2) for reimbursement of relocation costs; • 2 CFR 200.318(c)(1) for employee conflicts of interest; • 2 CFR 200.318(c)(2) for organizational conflicts of interest; • 2 CFR 200.320(b)(2) for selection and awarding of contracts for competitive proposals; • 2 CFR 200.319(d) for minimum evaluation criteria for bids and proposals. During testing we noted that the County did not have sufficient written policies addressing the above requirements. Failure to adopt and implement policies could lead to noncompliance with federal requirements. We recommend the County approve and implement the above policies to ensure compliance with federal requirements.
CONDITION: Employee time and effort reports were not consistently completed, certified, and maintained in accordance with the grant requirements. The auditor's review of a sample of employee timesheets found discrepancies in how time was allocated and reported for federal projects versus the PALM’s internal records. CRITERIA: The PALM is required by federal grant guidelines, specifically 2 CFR 200.430, to maintain internal controls over all aspects of their federal awards. This includes accurate and consistent documentation of personnel activity reports, timesheets, and payroll distribution records to support the direct labor costs charged to federal awards. CAUSE: The PALM lacked a formal, documented policy and procedure for tracking, certifying, and approving employee time spent on grant-related activities. Insufficient training was provided to employees and supervisors regarding the specific documentation requirements for federal grants. This resulted in personnel recording their time using inconsistent methods, including estimations at the end of a pay period, which increased the risk of inaccurate billing. EFFECT: Inaccurate time allocation led to the questioning of $95,618 in costs charged to the federal award. Since the timekeeping records did not provide reliable assurance that employee compensation was accurately charged, a portion of the labor costs was unsupported. This finding exposes the PALM to the risk of having to repay the federal agency for unallowable costs and could impact future grant funding. RECOMMENDATION: We recommend that the PALM utilize a time management software which integrates with their payroll processing, to easily identify direct labor costs related to the federal program. VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION: The PALM agrees with the finding, and started utilizing a new time management software in 2025 to prevent overbilling of direct labor costs. QUESTIONED COSTS: A total of $77,538 in salaries and $18,080 in benefits were calculated as questioned costs, based on annualized differences from testing.
Finding 2023-002, Timesheet – Timekeeping (Assistance Listing 93.567 and 93.576) Criteria: 2 CFR § 200.430 requires that the distribution of salary and wages charged to federal awards be based on actual employee activity as reflected in personnel activity reports (timesheets), prepared after-the-fact, and includes the total activity for which employees were compensated. Condition and Context: The Organization’s current timesheet does not include the allocation of hours worked by program, neither the schedule provided that support employees’ payroll allocation agreed for 14 out of the 48 sampled selected. Cause: Internal controls over the accurate distribution of hours on the timesheets were not operating effectively or designed properly as well as the worksheets that support the payroll allocation. Effect: The timesheets or worksheets do not support the allocation of time charged to the programs. Identification as a repeat finding: No. Questioned costs: None. Recommendation: We recommend that the Organization strengthen its policies and procedures for the timekeeping and distribution of the employees’ hours in accordance with the requirements of the federal programs.
Finding 2023-002 – Internal Control over Compliance (Material Weakness) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing Number: 93.959 Federal Award Identification Number: 43CAZ03215 Award Period: January 1, 2023 – December 31, 2023 Type of Finding: Material Weakness in internal control over compliance Criteria: The cost principles in 2 CFR Part 200, subpart E (Cost Principles) prescribe requirements for allowable costs relative to compensation and substantiation requirements specifically, 2 CFR Part 200.430(i) states “Cost must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated.” Condition: Employee change of status forms are not consistently maintained in accordance with applicable requirements. Questioned Costs: None. Context: 10 Employee files that were selected for verification disclosed 3 instances where forms were not available for review. Cause: Employee change of status forms or offer letters were not maintained on file or available for review. Effect: Inability to review employee change of status forms or offer letters limits the ability to verify costs allowability as required. As a result of the missing forms, it is not possible to fully ascertain compliance with allowable costs as required by 2 CFR 200.430. Repeat Finding: Yes Recommendation: Offer letters or employee change of status forms should be maintained on file. We recommend management implement a second layer of review of personnel files. Views of Responsible Official: Since the hiring of the Executive Director in March of 2023, we have implemented the following: Created A Human Resources Department, which did not exist at CRA before 2023. Hired a Human Resources Director to oversee department. Initiated a comprehensive HR information system where staff can review their pay, track their time, and review benefits. Initiated the process of uploading personnel information to our new system, while keeping backups secured. This includes hiring documentation and change of status forms for employees.
Criteria: Under the Uniform Guidance, specifically 2 CFR 200.430, charges to Federal awards for compensation must be supported by a system of internal control which provides reasonable assurance that costs are allocated appropriately and accurately. Per 2 CFR §200.403, allowable costs must be "necessary, reasonable, and adequately documented." Additionally, 2 CFR §200.302(b)(3) requires non-Federal entities to maintain records that sufficiently detail financial transactions to support Federal expenditures. Condition: During our testing of payments charged to the federal major program, we noted that employee timesheets lacked evidence of review and approval. Certain employees charged to the grant did not prepare timesheets and a separate tracking system was used. Federal regulations require that expenditures charged to Federal awards be properly reviewed, approved, and documented to ensure allowability and compliance with grant terms. Cause: The Federal program was new to the organization and controls over the program had not been fully established. Turnover in the accounting department contributed to the lack of resources for tracking these costs. Effect or potential effect: Management provided documentation on personnel costs allocated to the program, but was unable to provide evidence of review. Lack of review increases the risk of unauthorized or unallowable costs being charged to the Federal award, potentially leading to questioned costs and noncompliance with Federal grant requirements. Context: This issue applied to less than 10% of the grant expenditures, $54,505 out of the $897,736 of total expenditures charged to the grant. Recommendation: Management should review the requirements of CFR 200.430 and ensure that current processes, whether digital or hard-copy driven, are consistent with the requirements of the Uniform Guidance. In addition, management should consider adding additional staff to its accounting and/or grants management team. Views of responsible officials: Management will evaluate systems and processes to ensure time tracking procedures meet the standards outlined in the Uniform Guidance.
The U.S. Department of Agriculture (USDA) has adopted the Office of Management and Budget's Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards as codified in 2 CFR Part 200, through its own regulation at 2 CFR § 400.1. This adoption gives regulatory effect to 2 CFR § 200.430(f) which governs the allowability of fringe benefits under Federal awards. 2 CFR § 200.430(f) states that fringe benefits are allowable provided they are reasonable and required by law, employeremployee agreement or established policy. USDA's incorporation of this provision via 2 CFR § 400.1 makes it enforceable for all USDA-funded programs and awards including the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program. OGAPP Manual 100.3, B2.4 Personnel Costs, states that even though costs of overtime/bonuses are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3% of an employee's gross wages (not including fringes) or $1,500, whichever is less. The Ohio Department of Health (ODH) program administrator must approve all bonuses and enter a comment in GMIS in the project comments section. The District received approval from ODH via GMIS in 2023 for bonuses to be paid, however, due to a lack of internal controls, the bonuses were in excess of the amounts allowed under OGAPP (3%,or $1,500). The excess bonus amounts considered unallowable for the WIC program totaled $1,933. The unallowable bonus amounts paid are under the $25,000 federal threshold and therefore would not be considered as questioned costs for the program. The District should establish and implement internal controls to ensure all requirements from the federal and pass-through entities are followed to help ensure compliance and reduce the risk of misuse of funds.
2023-003 – Lack of Documented Approval for Payroll Transactions Program: ALN# 47.070 = Computer and Information Science and Engineering Federal Agency: National Science Foundation Federal Award Identification Number(s): 2216614, 2122756 Period: Year Ended December 31, 2023 Criteria: Under 2 CFR § 200.430, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed and must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Condition: During testing of payroll expenditures, the Organization was unable to provide documentation demonstrating supervisory approval for 7 of the 40 payroll transactions sampled. While payroll amounts appeared consistent with employee job description, pay rates, and timesheets, the required evidence of review and approval (e.g., approved timesheets, electronic timekeeping approval logs, or supervisor sign-offs) was not available for these items. Cause: The Organization’s existing payroll approval process is not consistently followed. Management reported that supervisory approval of employee hours is performed, but documentation is not always retained due to inconsistent use of the timekeeping system. Effect: Failure to maintain proper documentation of payroll approvals increased the risk that payroll costs charged to Federal programs may be unallowable or inaccurately allocated and unauthorized or incorrect payroll charges may go undetected. Questioned Costs: No questioned costs identified. Context: This sample was not intended to be, and was not, a statistically valid sample. Repeat Finding: No Recommendation: We recommend that the Organization: • Strengthen internal controls to ensure that all payroll transactions include documented supervisory approval prior to processing. • Ensure consistent use of the approved timekeeping system and require management to complete standardized approvals. • Implement periodic monitoring of payroll records to verify compliance with the approval process. Views of Responsible Officials: See management corrective action plan attached.
Condition: Employees who charged 100% of their time to the grant lacked required certifications or timecards documenting that their time was spent exclusively on grant-related activities. - In several instances, no timecards were available. - In other cases, available timecards showed no evidence of review or approval. - Timecards did not indicate program activity. - Timecards lacked evidence of supervisor approval. - Employees whose time was allocated to multiple programs had no indication of how their time was allocated on the time card. We did note, however, that most allocated employees were working on multiple contracts within the same Federal program, and that costs were allocated among the programs based on the number of beds in each facility, which appears to be a reasonable methodology. - Salaried employees did not have a method for indicating time worked. Cause: The organization failed to implement adequate internal controls to ensure compliance with federal timekeeping and documentation requirements for personnel expenses. Additionally, there appears to be a lack of understanding of the documentation and certification requirements under 2 CFR Part 200, Subpart E. Possible effect: The lack of proper documentation and certification creates a risk that unallowable costs were charged to the grant. Questioned cost: Undetermined. Recommendation: Develop and implement policies and procedures to ensure that timecards and/or certifications are completed and retained for all employees who charge 100% of their time to the grant. Implement a compliant system of time and effort reporting for employees whose time is allocated across multiple activities to align with 2 CFR §200.430(g)(vi). Conduct training for all employees and supervisors on the requirements for documenting and certifying time and effort for federal grants. Perform periodic reviews of timekeeping records and compensation charges to verify compliance with federal requirements.Views of responsible officials: During this period, Hope the Mission experienced rapid organizational growth in which our internal infrastructure had not yet caught up to support the significant growth in programs and funding. Since then, management changed our 3rd party payroll provider in order to better support our payroll and reporting needs. As part of this transition, we worked closely with our new payroll provider to implement job-costing functionality that will accurately track time across grants funded programs. In addition, we have established a process requiring department leads to review and approve all timesheets prior to submission. We are also partnering with our new 3rd party payroll provider to set up time allocation for salaried employees.
FINDING 2023-005 – Allowable Costs: Significant Deficiency over Internal Controls over Compliance Assistance Listing Number Federal Agency/Pass-through Entity – Program Name Award Year Questioned Costs 64.033 VA Supportive Services for Veteran Families Program 2023 $0 Criteria: The time and effort reporting or compensation of personal services 2 CFR section 200.430 notes a non-federal entity must have written policies surrounding time and effort reporting that are consistently applied to both federal and non-federal activities. The actual percentage of employees’ time must be recorded and documented per funding source and not by budgets. Documentation must be maintained to support allocations for non-payroll and payroll disbursements charged to the grant. 2 CFR section 200.405 relates to allocable costs. A cost is allocable to a federal award if the goods and services involved are chargeable to that award in accordance with relative benefits received. Costs are allocable if they: • Are incurred specifically for the federal award • Benefit both the federal award and other work of the non-federal entity and can be distributed in reasonable proportion to the benefits received; or • Are necessary to the overall operation of the non-federal entity and are assignable in part to the federal award. Condition/Context: In a sample of 25 payroll disbursements, 11 salaried employees lacked adequate documentation to support the allocation of time and effort to federal programs. Additionally, 4 out of 25 non-payroll disbursements lacked a documented methodology or supporting evidence to justify the allocation of costs between programs. Effect: Expenses charged to the grant are not supported by records. Cause: There was turnover in the Organization which caused the inability to produce or find supporting documentation on how allocations are created inside the system. Repeat finding: This is not a repeat finding. Recommendation: The Organization should have written policies surrounding time and effort reporting and ensure the methodology is supported by source documents for all transactions. Views of responsible officials and planned corrective actions: Management agrees with the recommendation and has developed a corrective action plan to address the finding.
Finding 2023-002: 21.027 - Coronavirus State and Local Fiscal Recovery:COVID-19 Compliance Requirement: Allowable Costs/Cost Principles - Significant Deficiency Criteria: 2 CFR 200.430, subpart I - Compensation-personal service, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: • Be supported by a system of internal control which provides reasonable assuance that the charges are accurate, allowable, and properly allocated; • Reasonably reflect the total activity for which the employee is compensated; and • Be supported by documentation such as time sheets, time cards, or equivalent records that are approved by a supervisor with firsthand knowledge of the work performed. Condition: During testing of payroll transactions, it was noted that one employee out of eighteen tested charged to the federal award did not have a completed and approved timecard to support payroll costs for the period under review. As a result, the time and effort supporting payroll charges could not be verified. Effect: Without proper time and effort documentation, there is insufficient support to verify that payroll charges to the federal award accurately reflect the time worked on the project. This may result in unallowable costs being charged to the award. Questioned Cost: None Cause: The Organization did not consistently enforce its policy requiring employees to complete and submit time cards for all federally funded payroll costs. Recommendation: Management should ensure that all employees whose salaries are charged to federal awards complete and maintain appropriate time and effort documentation, such as signed time cards or certifications, in accordance with 2 CFR 200.430. Supervisors should review and approve these records regularly to verify the accuracy of payroll charges. Response: Implement procedures to ensure supervisors’ approval of all federally funded timecards by a set deadline. HR will run a “missing timecard report” each pay cycle to ensure time cards are properly completed. Will conduct annual training on federal compliance requirements.
Finding 2023-002: Lack of documentation of review and approval - Material Weakness Program name:Office for Coastal Management Assistance Listing: 11.473 Federal award Identification number: 20 NFWF 339630 Federal award year: 9/1/2020 - 9/30/2024 Federal awarding agency: U.S. Department of Commerce Criteria - In accordance with 2 CFR 200.303, recipients and subrecipients must establish, document and maintain effective internal control over Federal awards. These controls should be in compliance with Federal statutes, regulations, and the terms and conditions of the award, and should align with standards such as the “Standards for Internal Control in the Federal Government” (Green Book) or the COSO framework. This includes controls over: Payroll: Ensuring labor charges are accurate, allowable, and properly approved (2 CFR 200.430). Expenses: Ensuring proper documentation and approval. (2 CFR 200.400(d) ) Reporting: Ensuring financial reports are accurate, complete, and reviewed prior to submission (2 CFR 200.328). Condition - The Organization has limited written processes of certain transaction classes. There was a pervasive lack of documentation of approval over transactions, including payroll, expenses, and reporting. Cause - The Organization did not maintain or consistently apply documentation protocols for internal control reviews. Formal documentation practices were not in place during the audit period. Effect - Lack of documentation as evidence that controls over compliance were being performed. Documentation should be maintained as evidence that sufficient control activities are in place and would effectively prevent or detect and correct noncompliance. Controls must be followed for every transaction and documentation of the control being performed must be maintained. Questioned costs - None identified. Perspective - The deficiency was pervasive across multiple compliance areas and was not isolated to a specific transaction or department. The scope indicates a systemic control weakness during the audit period. Identification of Repeat Findings - This is a repeat finding from the prior year (Finding 2022-002). As a result of the 2022 audit report, issued in October 2025, the Organization began the process of developing updated policies for compliance. In 2025, the Organization formally adopted new policies and procedures that align with the internal control standards per 2 CFR Part 200. Recommendation - We recommend that the Organization ensure updated policies and procedures are implemented and consistently applied. This includes: Documented review and approval of all transactions related to payroll, expenses, and reporting. Maintenance of written evidence supporting such reviews. Regular training and internal monitoring to ensure control procedures are consistently followed. Management response - Management agrees with this assessment and has committed to a corrective action plan. Management has also engaged with a new accounting firm to oversee the financial reporting functions at the Organization.
2 CFR § 300 codified in 45 CFR part 75 gives regulatory effect to the Department of Health and Human Services. 2 CFR § 200.302(b)(6) states the financial management system of each non-Federal entity must provide for written procedures to implement the requirements of 2 CFR § 200.305 Payment. Additionally, for Federal awards, the Uniform Guidance requires a written policy for the procurement requirements outlined in 2 CFR § 200.318(c)(1), 2 CFR § 200.318(c)(2), and 2 CFR § 200.320(B) 2 CFR 200.302(b)(7) requires written procedures for determining the allowability of costs in accordance with Subpart E-Cost Principles of this part and the terms and conditions of the Federal award. 2 CFR 200.430 states that costs of compensation are allowable to the extent that they satisfy the specific requirements of this part, and that the total compensation for individual employees: (1) Is reasonable for the services rendered and conforms to the established written policy of the non-Federal entity consistently applied to both Federal and non-Federal activities; (2) Follows an appointment made in accordance with a non-Federal entity's laws and/or rules or written policies and meets the requirements of Federal statute, where applicable; and (3) Is determined and supported as provided in paragraph (i) of this section, Standards for Documentation of Personnel Expenses, when applicable. 2 CFR 200.431 requires established written leave policies if the entity intends to pay fringe benefits. 2 CFR 200.464(a)(2) requires reimbursement of relocation costs to employees be in accordance with an established written policy must be consistently followed by the employer. 2 CFR 200.475 requires reimbursement and/or charges to be consistent with those normally allowed in like circumstances in the non-Federal entity's non-federally-funded activities and in accordance with non-Federal entity's written travel reimbursement policies. The General Health District did not have written policies as required by Uniform Guidance. The failure to implement written policies as required by Uniform Guidance could result in noncompliance with the District’s federal programs. The General Health District should adopt written policies in accordance with the Uniform Guidance.
Employee not paid approved salary rate and payroll allocation based on incorrect pay rate. Timesheets missing approval. 93.011 National Organizations for State and Local Officials 93.318 Protecting and Improving Health Globally: Building and Strengthening Public Health Impact, Systems, Capacity and Security 93.341 Analyses, Research and Studies to Address the Impact of CMS Programs on American Indian/Alaska Native (AI/AN) Beneficiaries and the Health Care System Serving these Beneficiaries 93.421 Strengthening Public Health Systems and Services Criteria: 2 CFR 200.430 states “Charges to Federal awards for salaries and wages 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; (ii) Be incorporated into the official records of the non Federal entity; (iii) Reasonably reflect the total activity for which the employee is compensated by the non Federal entity, not exceeding 100% of compensated activities." Condition: During our testing of payroll, we noted twenty one instances of incorrect pay rates, missing timesheet approvals and twenty four payroll allocations based on incorrect pay rates. We consider these to be a significant deficiency in internal control over compliance relating to activities allowed and unallowed and allowable costs/cost principles requirements and is not considered a repeated finding. Statistical sampling was not used in making sample selections. Questioned costs: $4,245 Effect: Employee compensation was not processed using the authorized salary rate, resulting in payroll allocations based on an incorrect pay rate. Additionally, timesheets lacked the required approval signatures. Overall this could result in an employee being incorrectly paid for time worked. Cause: This is due to lack of controls over document retention resulting from employee turnover. Recommendation: Auditors recommend the Organization maintain proper salary rate approval and ensure all pay rates are approved by an appropriate individual and properly paid to employees. We also recommend timesheets should be approved by an appropriate individual and payroll allocations should be based on proper salary rates. Views of Responsible Officials and Planned Corrective Actions: Management agrees with this Single Audit Finding and response is included in the Corrective Action Plan.
Material noncompliance and material weakness in internal control over compliance with allowable costs/cost principles requirements. Federal Agency: Department of Health and Human Services Program Title: Social Services Research and Demonstration Program Assistance Listing Number: 93.647 Project Number: 90XP0459-01-00 Award Period: August 31, 2022 – August 30, 2023 Criteria Nonfederal entities must follow the standards for documentation of personnel expenses set out at 2 CFR section 200.430(i) (the Uniform Guidance). Under those standards, charges to Federal awards for compensation must be based on records that accurately reflect the work performed. Those standards require that the records 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 nonfederal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. Budget estimates, alone, do not qualify as support for charges to Federal awards and must include after-the-fact reviews of interim charges to Federal awards based on actual activity. Condition The Organization utilized budget estimates for the allocation of compensation and fringe benefits to Federal awards and lacked the tracking of actual activity and related after-the-fact review of charges. Cause The Organization’s system of internal control was not designed appropriately to comply with the standards for documentation of personnel expenses as prescribed by the Uniform Guidance. Effect The allocation of personnel expenses and related fringe benefit were not properly supported. Questioned Costs The total payroll and fringe benefit costs of $618,611 were charged to the major program during the year ended December 31, 2023. Recommendation We recommend management update its payroll system to add procedures to capture and document an after-the fact determination of work effort for each employee to support the percentage of payroll cost allocated to federal programs.