AL number: 21.027 AL title: Coronavirus State and Local Fiscal Recovery Funds Federal award identification number and year: SLFRP4542 - 2023; HS2024-1262 - 2024 Name of federal agency: U.S. Department of Treasury Name of pass-through entity: Missouri Department of Economic Development; St. Louis County Department of Human Services Repeat finding: No Criteria: Under Uniform Guidance (2 CFR §200.430), compensation for personal services charged to federal awards must be based on records that accurately reflect the work performed and must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Condition: The Organization did not have a formalized process for the review and approval of payroll transactions, including the allocations of payroll costs to grants. Cause: The Organization did not implement sufficient internal controls over payroll processing and grant cost allocation. There is a lack of documented procedures, oversight, and personnel with the necessary expertise in federal grant compliance to ensure payroll costs are properly reviewed and allocated. Possible effect: The absence of a formal review and approval process for payroll and grant allocations increases the risk of inaccurate or unallowable costs being charged to federal awards. This could result in questioned costs, audit findings, and potential repayment of grant funds, as well as noncompliance with Uniform Guidance requirements. Questioned cost: None. Recommendation: The Organization should implement a formal payroll review and approval process that includes documented supervisory review of payroll registers and allocations. Additionally, establish a standardized methodology for allocating payroll costs to grants, supported by time and effort documentation. Assign responsibility to personnel with appropriate grant management expertise to oversee compliance with federal requirements. Maintain evidence of all reviews and approvals to support audit readiness. Views of responsible officials: Management agrees with this finding. See the Corrective Action Plan.
Assistance Listing Number: 10.728 Name of Federal Program: Inflation Reduction Act Hazardous Fuels Transportation Assistance Name of Federal Agency: Department of Agriculture Award Period: January 1, 2024 – December 31, 2024 Criteria or Specific Requirement: Per 2 CFR Part 200, non-federal entities receiving federal award must establish and maintain written policies and procedures addressing areas including, but not limited to, cash management (§200.302(b)(6)), allowability of costs (§200.302(b)(7)), procurement (§200.318-.326), compensation (§200.430(a)(1)), and fringe benefits (§200.431). Condition: ALC has not implemented all policies and procedures required by 2CFR Part 200, such as cash management, allowability of costs, procurement, compensation, and fringe benefits. Cause: ALC has not detailed its policies to conform with the requirements of the Uniform Guidance. Procurement policies and procedures have not been designed and implemented that adhere to Uniform Guidance requirements. Effect or Potential Effect: Without documented and implemented policies and procedures, ALC increases the risk of noncompliance with federal regulations, inconsistent application of requirements, unallowable costs being charged to federal awards, and potential questioned costs Context: Policies and procedures were inspected for compliance with the requirements of the Uniform Guidance. Repeat Finding: No Recommendation: ALC should develop, formally adopt, and implement all Uniform Guidance policies and procedures. Policies should be documented, communicated to relevant staff, and periodically reviewed to ensure ongoing compliance. Views of Responsible Officials: Management agrees with the finding and will implement procurement policies and procedures.
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, employer-employee 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 $1,907. 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.
2024-003 Internal Controls and Compliance over Allowable Costs and Activities - Payroll (Material Weakness and Material Noncompliance) Legal Services Corporation 09.744060 Basic Field Grant Grant Period: 1/1/2024 – 12/31/2024 Contract Number: 744060 U.S Department of Justice 16.575 Victims of Crime Act Grant Periods: 10/1/23-9/30/24 and 10/1/24 – 9/30/25 Contract Number: 4055104; 4055105 Supreme Court of Texas Basic Civil Legal Services Program Grant Period: 9/1/2023 – 8/31/2025 Contract Number: 26030 Criteria: Under 2 CFR Section 200.303(a) a non-Federal entity is required to establish and maintain internal controls over compliance with Federal statutes, regulations, and the terms and conditions of the Federal grant. In addition, under 2 CFR Section 200.430 – Compensation – personal services, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. Budget estimates may be used for interim accounting purposes, but budget estimates alone do not qualify as support for charges to Federal awards. The entity’s system of internal controls must include a process to review after-the-fact interim charges made to a Federal award to budget estimates and make any necessary adjustments such that the final amount charged to the Federal award is accurate, allowable and properly allocated. Texas Grant Management Standards also contains provisions for selected items of cost for Compensation – personal services which mirrors the requirements of 2 CFR Section 200.430. Condition: The Organization’s internal control process to compare actual time charged on the employee’s time sheet to the budget allocation charged to the grant to determine if budget estimates reflect reasonable approximations of the activities performed, did not consistently occur. For 16 of 75 payroll disbursements selected for testing, the allocation on the time sheet provided did not agree to the allocation of the employee’s wages to the program. In addition, of 9 of 75 payroll transactions selected for testing, the Organization was unable to provide a time sheet to substantiate the application of the employee’s time for that period. The finding appears to be a systemic issue. The sample was not statistically valid. Cause: Time sheets were not consistently compared against budget estimates by the Director of Finance. Time sheets could not be located for employees no longer employed by the Organization. Effect: Failure to review time sheets or maintain time sheets to support compensation allocations could result in an over/under statement of compensation charged to the Federal or State grants. Questioned Costs: (See chart) Perspective: There is not observable evidence of the Organization’s review and reconciliation of time sheets to budget estimates which affects both the allowable activities and allowable costs requirements. Repeat Finding: No Auditor’s Recommendation: We recommend the Organization review its timekeeping policies and procedures and provide additional training to employees to ensure time sheets are retained for all payroll transactions to support the allocation of compensation. We also recommend the Organization review and refine its policies to reconcile the percentage of hours charged on the time sheets to the budget estimates used to bill Federal and State grantors. This should be done in conjunction with monthly or quarterly billings (or other determined regular interval), at fiscal year end, and at the end of the grant year (if different from the Organization’s fiscal year). Views of Responsible Officials: We concur with the recommendation, please see Corrective Action Plan.
Finding 2024-002 Noncompliance and material weakness in internal control over compliance with allowable costs/cost principles requirements. Federal Agency: United States Department of Treasury Assistance Listing Number: 21.027 Assistance Listing Name: Coronavirus State and Local Fiscal Recovery Award Number: DA-202310-02403 Award Year: January 1, 2024 through December 31, 2024 Name of Pass-Through Entity: King County Regional Homelessness Authority Criteria Nonfederal entities must follow the standards for documentation of personnel expenses set out at 2 CFR section 200.430(i). Under those standards, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. Additionally, those standards require that the records a) reasonably reflect the total activity for which the employee is compensated by the nonfederal entity, not exceeding 100% of compensated activities; b) 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; and c) budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to Federal awards. Condition During our testing of the payroll costs charged to the major program, we noted that ACLT is allocating payroll costs for individual employees using budget estimates of time and effort on different activities. In December 2024, ACLT implemented processes to document after-the-fact determinations of time spent for each employee to support the allocations. However we noted the documentation was not completed for all employees selected for testing. We also found the documentation supporting the after-the-fact determinations was not completed timely for the pay period tested. Cause ACLT’s system of internal control is designed appropriately to capture and document after-the-fact determination of time and effort for each employee on different activities. However the controls were not found to be operating effectively for all of 2024. Effect The effect is that ACLT is not in compliance with the requirements of 2 CFR section 200.430(i). Payroll costs charged to the major program are not supported by documentation evidencing that those costs reasonably reflect the work performed on the activity. Questioned Costs Of the total expenditures of $2,008,301 charged to the major program in 2024, $1,913,220 are for payroll costs and related fringe benefits. Context ACLT maintains a timekeeping and payroll system for charges to federal awards that documents approved wage and salary rates, hours, and actual amounts paid to employees. However, the system does not include the documentation required in 2 CFR section 200.430(i) specifically related to documenting actual time and effort performed on different activities. The payroll charged to the major program includes a mix of employees that work 100% of their time on the major program activity and other employees that allocate their total hours to the major program activity and other activities. Of the $1,756,161 of gross payroll cost charged to the major program in 2024, 74% of that cost relates to employees that work 100% of their time on the major program activity; the remaining 26% of the cost relates to employees that allocate their total hours to the major program activity and other activities. Repeat Finding This is a repeat finding. Recommendation We recommend management ensure documentation for after-the-fact determination of work effort be completed and retained for each employee to support the percentage of payroll cost allocated to federal programs. We also recommend management complete documentation within the month following the end of the pay period end for actual time and effort performed on program activities. Timely documentation ensures allocations of payroll costs best represent actual time performed on the federal program. Views of Responsible Officials and Corrective Action Plan Management agrees with the finding and has provided the accompanying corrective action plan.
Program: ALL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Allowable Costs/Costs Principles (Payroll Costs) Repeat Finding: Yes Condition: Management did not review and approve the time and effort allocation of employees working under federal grants resulting in significant post-close adjustments. Criteria: In accordance with 2 CFR §200.430, the non-federal entity may compensate for personal services including all remuneration, paid currently or accrued, for services of employees rendered during the period of performance under the federal award, including but not necessarily limited to wages and salaries. The costs of compensation are allowable to the extent that they satisfy the specific requirements of this part. Additionally, as defined in 2 CFR Ch. II (1-1-18 Edition) §200.430(g), for compensation to members of nonprofit organizations, trustees, directors, associates, officers, or the immediate families thereof, determination must be made that such compensation is reasonable for the actual personal services rendered rather than a distribution of earnings in excess of costs. This may include director’s and executive committee member’s fees, incentive awards, allowances for off-site pay, incentive pay, location allowances, hardship pay, and cost-of-living differentials. Cause: Management did not review and approve the time and effort allocation of employees working under federal grants. Effect: If the time and allocation efforts of employees working under federal grants were not reviewed and approved in compliance with Uniform Guidance, the Foundation would not identify the compensation allocation and billing to the federal grants are reasonable amount. Questioned Costs: Unknown. Recommendation: We recommend that the Foundation review and approve the time and effort allocation of employees working under federal grants to ensure proper tracking and billing for compensation amount allowed per the federal award. Auditee Response and Corrective Action Plan: Refer to management’s corrective action plans. Auditor’s Conclusion: Finding remains as stated.
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.
Criteria: In accordance with 2 CFR Part 200.430(i), 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 assurance that charges are accurate, allowable, and properly allocated. Furthermore, budget estimates alone do not quality as support for charges to Federal awards. Condition: The Organization allocated personnel costs to Federal awards based on a percentage allocation and an after-the-fact review of the personnel costs allocated to the Federal awards was not performed on a periodic and consistent basis throughout the year. Cause: Management was not fully familiar with the standards for documentation of personnel expenses requirements required by the Uniform Guidance. In addition, management noted that the majority of employees whose time is allocated to the Federal awards solely spends their time on activities related to the Federal awards, thus management believes the percentage allocation utilized results in an accurate allocation of personnel costs. Possible effect: Payroll costs charged to Federal awards may not accurately represent the actual time incurred on the award. Questioned cost: None Recommendation: We recommend that the Organization implement a policy and methodology that more accurately allocates payroll costs to the Federal awards. The methodology utilized should include a consistent and routine after-the-fact review to ensure that payroll costs are accurately allocated. Views of responsible officials: Management agrees with the finding and will form and implement a revised methodology for allocating payroll costs to the Federal awards.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-107 Incorrect Costs were Submitted for Reimbursement (Initially reported 2024) Assistance Listing Number: 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Rural Telemedicine Grants Compliance Requirement: Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: GA142923 (2021), G2846293 (2022), and GA3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $68 known and $589 likely Condition: The September 2024 reimbursement request included one instance, out of 37 items tested, where calculations of personnel expenditures allocable to the grant used an inaccurate amount, resulting in an overcharge of personnel expenditures. In calculating the allocable expenditure, wages for the month of August, which had previously been charged to the grant, were used to calculate the amount allocable to the grant for the month of September. Gross wages for August exceeded gross wages for September. Wages for both months were allowable and allocable to the grant. This is not a systemic problem but an isolated occurrence resulting in an immaterial difference in the amount reimbursed and the amount that should have been requested for September 2024 wages paid. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Per 2 CFR 200.430(g), costs charged to federal awards must be supported by records that- support the distribution of salaries and wages among specific activities, while reflecting the total activity of the employee, not to exceed 100% of compensated activities. Cause: Wages requested for reimbursement in September 2024 reflected the wages paid in August 2024 in error and were not detected during the review process over the reimbursement request. Effect: Personnel costs charged to the award were based on amounts exceeding 100% of the employee’s compensation for one month, resulting in an overcharge to the award. Recommendation: Review of costs allocated and requested for reimbursement should incorporate consideration of the period the costs were incurred. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have strengthened our review process for reimbursement requests to prevent similar errors. Finance staff verify payroll periods against reimbursement periods before submission, and supervisors perform an additional review. This process includes careful cross-checking against the appropriate pay periods. This was an isolated occurrence with immaterial impact, but corrective steps will ensure accuracy in future requests.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-107 Incorrect Costs were Submitted for Reimbursement (Initially reported 2024) Assistance Listing Number: 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Rural Telemedicine Grants Compliance Requirement: Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: GA142923 (2021), G2846293 (2022), and GA3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $68 known and $589 likely Condition: The September 2024 reimbursement request included one instance, out of 37 items tested, where calculations of personnel expenditures allocable to the grant used an inaccurate amount, resulting in an overcharge of personnel expenditures. In calculating the allocable expenditure, wages for the month of August, which had previously been charged to the grant, were used to calculate the amount allocable to the grant for the month of September. Gross wages for August exceeded gross wages for September. Wages for both months were allowable and allocable to the grant. This is not a systemic problem but an isolated occurrence resulting in an immaterial difference in the amount reimbursed and the amount that should have been requested for September 2024 wages paid. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Per 2 CFR 200.430(g), costs charged to federal awards must be supported by records that- support the distribution of salaries and wages among specific activities, while reflecting the total activity of the employee, not to exceed 100% of compensated activities. Cause: Wages requested for reimbursement in September 2024 reflected the wages paid in August 2024 in error and were not detected during the review process over the reimbursement request. Effect: Personnel costs charged to the award were based on amounts exceeding 100% of the employee’s compensation for one month, resulting in an overcharge to the award. Recommendation: Review of costs allocated and requested for reimbursement should incorporate consideration of the period the costs were incurred. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have strengthened our review process for reimbursement requests to prevent similar errors. Finance staff verify payroll periods against reimbursement periods before submission, and supervisors perform an additional review. This process includes careful cross-checking against the appropriate pay periods. This was an isolated occurrence with immaterial impact, but corrective steps will ensure accuracy in future requests.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-107 Incorrect Costs were Submitted for Reimbursement (Initially reported 2024) Assistance Listing Number: 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Rural Telemedicine Grants Compliance Requirement: Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: GA142923 (2021), G2846293 (2022), and GA3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $68 known and $589 likely Condition: The September 2024 reimbursement request included one instance, out of 37 items tested, where calculations of personnel expenditures allocable to the grant used an inaccurate amount, resulting in an overcharge of personnel expenditures. In calculating the allocable expenditure, wages for the month of August, which had previously been charged to the grant, were used to calculate the amount allocable to the grant for the month of September. Gross wages for August exceeded gross wages for September. Wages for both months were allowable and allocable to the grant. This is not a systemic problem but an isolated occurrence resulting in an immaterial difference in the amount reimbursed and the amount that should have been requested for September 2024 wages paid. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Per 2 CFR 200.430(g), costs charged to federal awards must be supported by records that- support the distribution of salaries and wages among specific activities, while reflecting the total activity of the employee, not to exceed 100% of compensated activities. Cause: Wages requested for reimbursement in September 2024 reflected the wages paid in August 2024 in error and were not detected during the review process over the reimbursement request. Effect: Personnel costs charged to the award were based on amounts exceeding 100% of the employee’s compensation for one month, resulting in an overcharge to the award. Recommendation: Review of costs allocated and requested for reimbursement should incorporate consideration of the period the costs were incurred. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have strengthened our review process for reimbursement requests to prevent similar errors. Finance staff verify payroll periods against reimbursement periods before submission, and supervisors perform an additional review. This process includes careful cross-checking against the appropriate pay periods. This was an isolated occurrence with immaterial impact, but corrective steps will ensure accuracy in future requests.
2024-001 Compensation for Personal Services Head Start Cluster – Assistance Listing No. 93.600 Award Numbers: 08CH010736-06 – Award Period: December 1, 2023 through June 30, 2024 08CH012759-01 – Award Period: July 1, 2024 through November 30, 2024 MOEAI-202366770 – Award Period: July 1, 2023 through June 30, 2024 MOEAI-202474487 – Award Period: July 1, 2024 through June 30, 2025 Maternal, Infant and Early Childhood Home Visiting Grant – Assistance Listing No. 93.870 Award Numbers: CTGG1 QAAA 2024*2428 – Award Period: October 1, 2023 through September 30, 2024 CTGG1 QAAA 2025*2585 – Award Period: October 1, 2024 through September 30, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Condition: During our testing of time and effort records we noted that although timesheets were kept, they do not identify time spent working on different funding sources/cost objectives, so they were not used to calculate wages charged to the Federal awards tested. Instead, budgeted allocations were used, and the Organization could not support the allocation methodology(ies) applied to four out of the ten sampled employees. Criteria: According to 2 CFR Part 200.430(i)(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 (for IHE, this per the IHE's definition of IBS); (iv) Encompass federally-assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity's written policy; (v) Comply with the established accounting policies and practices of the non-Federal entity (See paragraph (h)(1)(ii) above for treatment of incidental work for IHEs.); and (vii) Support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. (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; C. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT (Continued) Criteria (Concluded): (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 adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated. Questioned Costs: Not determinable. Cause: The Organization did not document allocation methodology(ies) reflecting reasonable approximations of the activity actually performed for sampled employees in positions other than teachers and teaching assistants. Budget estimates were used for interim accounting purposes, however, there was no documented process to perform periodic after-the-fact reviews of interim charges nor adjustments made to ensure final amounts charged were properly allocated. Effect: Costs for salaries and wages were not fully supported by documentation in accordance with 2 CFR Part 200.430. Allowable costs could potentially be overpaid or underpaid or disallowed and required to be paid back to the Federal awarding agency (and/or pass-through entity). Recommendation: The Organization should strengthen policies and procedures to support a system of internal control which provides a reasonable assurance that the charges to Federal awards for salaries and wages are accurate, allowable, and properly allocated. This might include: 1. Enhance timesheet tracking to charge actual time spent working on different funding sources/cost objectives, or 2. Establishing a process to periodically review after-the-fact interim charges made to Federal awards based on budget estimates, make timely adjustments to ensure final amounts charged to Federal awards are accurate, allowable, and properly allocated, and document their reconciliation. Views of Responsible Officials and Planned Corrective Actions: Family Star acknowledges the FY24 finding related to labor allocation. During that fiscal year, the organization experienced several operational challenges, including insufficient documentation and oversight of labor allocation reporting. These administrative issues were contributing factors in a broader leadership restructuring, which included the elimination of five middle management positions. As a result, responsibilities for labor allocation were reassigned to ensure proper oversight. Since that time, Family Star has taken intentional steps to strengthen internal controls and improve the accuracy and consistency of key administrative functions. Labor time reporting is now aligned with organizational slot distribution across programs and funding sources to ensure compliance and transparency moving forward. To further reinforce accountability, we have implemented a new monthly monitoring procedure. On the first Wednesday of each month, the Senior Director of Community Partnerships and the HR Specialist jointly review and archive labor allocation records. This process ensures allocations are preserved, updates are made in a timely and compliant manner, and labor costs are supported by accurate documentation. These measures are designed to increase transparency, enhance internal controls, and ensure labor allocations are properly managed going forward.
2024-001 Compensation for Personal Services Head Start Cluster – Assistance Listing No. 93.600 Award Numbers: 08CH010736-06 – Award Period: December 1, 2023 through June 30, 2024 08CH012759-01 – Award Period: July 1, 2024 through November 30, 2024 MOEAI-202366770 – Award Period: July 1, 2023 through June 30, 2024 MOEAI-202474487 – Award Period: July 1, 2024 through June 30, 2025 Maternal, Infant and Early Childhood Home Visiting Grant – Assistance Listing No. 93.870 Award Numbers: CTGG1 QAAA 2024*2428 – Award Period: October 1, 2023 through September 30, 2024 CTGG1 QAAA 2025*2585 – Award Period: October 1, 2024 through September 30, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Condition: During our testing of time and effort records we noted that although timesheets were kept, they do not identify time spent working on different funding sources/cost objectives, so they were not used to calculate wages charged to the Federal awards tested. Instead, budgeted allocations were used, and the Organization could not support the allocation methodology(ies) applied to four out of the ten sampled employees. Criteria: According to 2 CFR Part 200.430(i)(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 (for IHE, this per the IHE's definition of IBS); (iv) Encompass federally-assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity's written policy; (v) Comply with the established accounting policies and practices of the non-Federal entity (See paragraph (h)(1)(ii) above for treatment of incidental work for IHEs.); and (vii) Support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. (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; C. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT (Continued) Criteria (Concluded): (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 adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated. Questioned Costs: Not determinable. Cause: The Organization did not document allocation methodology(ies) reflecting reasonable approximations of the activity actually performed for sampled employees in positions other than teachers and teaching assistants. Budget estimates were used for interim accounting purposes, however, there was no documented process to perform periodic after-the-fact reviews of interim charges nor adjustments made to ensure final amounts charged were properly allocated. Effect: Costs for salaries and wages were not fully supported by documentation in accordance with 2 CFR Part 200.430. Allowable costs could potentially be overpaid or underpaid or disallowed and required to be paid back to the Federal awarding agency (and/or pass-through entity). Recommendation: The Organization should strengthen policies and procedures to support a system of internal control which provides a reasonable assurance that the charges to Federal awards for salaries and wages are accurate, allowable, and properly allocated. This might include: 1. Enhance timesheet tracking to charge actual time spent working on different funding sources/cost objectives, or 2. Establishing a process to periodically review after-the-fact interim charges made to Federal awards based on budget estimates, make timely adjustments to ensure final amounts charged to Federal awards are accurate, allowable, and properly allocated, and document their reconciliation. Views of Responsible Officials and Planned Corrective Actions: Family Star acknowledges the FY24 finding related to labor allocation. During that fiscal year, the organization experienced several operational challenges, including insufficient documentation and oversight of labor allocation reporting. These administrative issues were contributing factors in a broader leadership restructuring, which included the elimination of five middle management positions. As a result, responsibilities for labor allocation were reassigned to ensure proper oversight. Since that time, Family Star has taken intentional steps to strengthen internal controls and improve the accuracy and consistency of key administrative functions. Labor time reporting is now aligned with organizational slot distribution across programs and funding sources to ensure compliance and transparency moving forward. To further reinforce accountability, we have implemented a new monthly monitoring procedure. On the first Wednesday of each month, the Senior Director of Community Partnerships and the HR Specialist jointly review and archive labor allocation records. This process ensures allocations are preserved, updates are made in a timely and compliant manner, and labor costs are supported by accurate documentation. These measures are designed to increase transparency, enhance internal controls, and ensure labor allocations are properly managed going forward.
2024-001 Compensation for Personal Services Head Start Cluster – Assistance Listing No. 93.600 Award Numbers: 08CH010736-06 – Award Period: December 1, 2023 through June 30, 2024 08CH012759-01 – Award Period: July 1, 2024 through November 30, 2024 MOEAI-202366770 – Award Period: July 1, 2023 through June 30, 2024 MOEAI-202474487 – Award Period: July 1, 2024 through June 30, 2025 Maternal, Infant and Early Childhood Home Visiting Grant – Assistance Listing No. 93.870 Award Numbers: CTGG1 QAAA 2024*2428 – Award Period: October 1, 2023 through September 30, 2024 CTGG1 QAAA 2025*2585 – Award Period: October 1, 2024 through September 30, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Condition: During our testing of time and effort records we noted that although timesheets were kept, they do not identify time spent working on different funding sources/cost objectives, so they were not used to calculate wages charged to the Federal awards tested. Instead, budgeted allocations were used, and the Organization could not support the allocation methodology(ies) applied to four out of the ten sampled employees. Criteria: According to 2 CFR Part 200.430(i)(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 (for IHE, this per the IHE's definition of IBS); (iv) Encompass federally-assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity's written policy; (v) Comply with the established accounting policies and practices of the non-Federal entity (See paragraph (h)(1)(ii) above for treatment of incidental work for IHEs.); and (vii) Support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. (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; C. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT (Continued) Criteria (Concluded): (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 adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated. Questioned Costs: Not determinable. Cause: The Organization did not document allocation methodology(ies) reflecting reasonable approximations of the activity actually performed for sampled employees in positions other than teachers and teaching assistants. Budget estimates were used for interim accounting purposes, however, there was no documented process to perform periodic after-the-fact reviews of interim charges nor adjustments made to ensure final amounts charged were properly allocated. Effect: Costs for salaries and wages were not fully supported by documentation in accordance with 2 CFR Part 200.430. Allowable costs could potentially be overpaid or underpaid or disallowed and required to be paid back to the Federal awarding agency (and/or pass-through entity). Recommendation: The Organization should strengthen policies and procedures to support a system of internal control which provides a reasonable assurance that the charges to Federal awards for salaries and wages are accurate, allowable, and properly allocated. This might include: 1. Enhance timesheet tracking to charge actual time spent working on different funding sources/cost objectives, or 2. Establishing a process to periodically review after-the-fact interim charges made to Federal awards based on budget estimates, make timely adjustments to ensure final amounts charged to Federal awards are accurate, allowable, and properly allocated, and document their reconciliation. Views of Responsible Officials and Planned Corrective Actions: Family Star acknowledges the FY24 finding related to labor allocation. During that fiscal year, the organization experienced several operational challenges, including insufficient documentation and oversight of labor allocation reporting. These administrative issues were contributing factors in a broader leadership restructuring, which included the elimination of five middle management positions. As a result, responsibilities for labor allocation were reassigned to ensure proper oversight. Since that time, Family Star has taken intentional steps to strengthen internal controls and improve the accuracy and consistency of key administrative functions. Labor time reporting is now aligned with organizational slot distribution across programs and funding sources to ensure compliance and transparency moving forward. To further reinforce accountability, we have implemented a new monthly monitoring procedure. On the first Wednesday of each month, the Senior Director of Community Partnerships and the HR Specialist jointly review and archive labor allocation records. This process ensures allocations are preserved, updates are made in a timely and compliant manner, and labor costs are supported by accurate documentation. These measures are designed to increase transparency, enhance internal controls, and ensure labor allocations are properly managed going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-107 Incorrect Costs were Submitted for Reimbursement (Initially reported 2024) Assistance Listing Number: 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Rural Telemedicine Grants Compliance Requirement: Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: GA142923 (2021), G2846293 (2022), and GA3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $68 known and $589 likely Condition: The September 2024 reimbursement request included one instance, out of 37 items tested, where calculations of personnel expenditures allocable to the grant used an inaccurate amount, resulting in an overcharge of personnel expenditures. In calculating the allocable expenditure, wages for the month of August, which had previously been charged to the grant, were used to calculate the amount allocable to the grant for the month of September. Gross wages for August exceeded gross wages for September. Wages for both months were allowable and allocable to the grant. This is not a systemic problem but an isolated occurrence resulting in an immaterial difference in the amount reimbursed and the amount that should have been requested for September 2024 wages paid. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Per 2 CFR 200.430(g), costs charged to federal awards must be supported by records that- support the distribution of salaries and wages among specific activities, while reflecting the total activity of the employee, not to exceed 100% of compensated activities. Cause: Wages requested for reimbursement in September 2024 reflected the wages paid in August 2024 in error and were not detected during the review process over the reimbursement request. Effect: Personnel costs charged to the award were based on amounts exceeding 100% of the employee’s compensation for one month, resulting in an overcharge to the award. Recommendation: Review of costs allocated and requested for reimbursement should incorporate consideration of the period the costs were incurred. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have strengthened our review process for reimbursement requests to prevent similar errors. Finance staff verify payroll periods against reimbursement periods before submission, and supervisors perform an additional review. This process includes careful cross-checking against the appropriate pay periods. This was an isolated occurrence with immaterial impact, but corrective steps will ensure accuracy in future requests.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-107 Incorrect Costs were Submitted for Reimbursement (Initially reported 2024) Assistance Listing Number: 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Rural Telemedicine Grants Compliance Requirement: Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: GA142923 (2021), G2846293 (2022), and GA3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $68 known and $589 likely Condition: The September 2024 reimbursement request included one instance, out of 37 items tested, where calculations of personnel expenditures allocable to the grant used an inaccurate amount, resulting in an overcharge of personnel expenditures. In calculating the allocable expenditure, wages for the month of August, which had previously been charged to the grant, were used to calculate the amount allocable to the grant for the month of September. Gross wages for August exceeded gross wages for September. Wages for both months were allowable and allocable to the grant. This is not a systemic problem but an isolated occurrence resulting in an immaterial difference in the amount reimbursed and the amount that should have been requested for September 2024 wages paid. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Per 2 CFR 200.430(g), costs charged to federal awards must be supported by records that- support the distribution of salaries and wages among specific activities, while reflecting the total activity of the employee, not to exceed 100% of compensated activities. Cause: Wages requested for reimbursement in September 2024 reflected the wages paid in August 2024 in error and were not detected during the review process over the reimbursement request. Effect: Personnel costs charged to the award were based on amounts exceeding 100% of the employee’s compensation for one month, resulting in an overcharge to the award. Recommendation: Review of costs allocated and requested for reimbursement should incorporate consideration of the period the costs were incurred. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have strengthened our review process for reimbursement requests to prevent similar errors. Finance staff verify payroll periods against reimbursement periods before submission, and supervisors perform an additional review. This process includes careful cross-checking against the appropriate pay periods. This was an isolated occurrence with immaterial impact, but corrective steps will ensure accuracy in future requests.
2024-106 Lack of Time and Effort Documentation Policy (Initially reported 2024) Assistance Listing Number: 93.224, 93.527 and 93.211. Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program, and Rural Telemedicine Grants Compliance Requirement: Allowable Activities and Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H8006452 (2024 and 2023), H2E45500 (2022), H8K49674 (2023), COVID-19 H2E50094 (2023), H8N53812 (2024), H8L50549 (2023), COVID-19 H8G48569 (2022), GA142923 (2021), G2846293(2022) and G3949501 (2023) Finding Type: Material Weakness in Internal Control Questioned Costs: $0 Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. This is a systematic issue. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under eCFR 2 CFR 200.430 – Compensation – personal services budget estimates do not qualify as support for charges to federal awards. Cause: The Organization has not put into practice a procedure where records are kept with employee salaries spent by hour on individual grants to substantiate the amount of budgeted FTE used on the reimbursement requests. Effect: Budgeted FTE used for reimbursement requests may be inaccurate resulting in incorrect amounts being requested for reimbursement. Recommendation: The Organization should put in place procedures to accurately document employee hours spent on each of the federal awards to support the budgeted FTE used on the reimbursement requests. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward.
2024-107 Incorrect Costs were Submitted for Reimbursement (Initially reported 2024) Assistance Listing Number: 93.211 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Rural Telemedicine Grants Compliance Requirement: Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: GA142923 (2021), G2846293 (2022), and GA3949501 (2023) Finding Type: Significant Deficiency in Internal Control Questioned Costs: $68 known and $589 likely Condition: The September 2024 reimbursement request included one instance, out of 37 items tested, where calculations of personnel expenditures allocable to the grant used an inaccurate amount, resulting in an overcharge of personnel expenditures. In calculating the allocable expenditure, wages for the month of August, which had previously been charged to the grant, were used to calculate the amount allocable to the grant for the month of September. Gross wages for August exceeded gross wages for September. Wages for both months were allowable and allocable to the grant. This is not a systemic problem but an isolated occurrence resulting in an immaterial difference in the amount reimbursed and the amount that should have been requested for September 2024 wages paid. The sample was not statistically valid. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Per 2 CFR 200.430(g), costs charged to federal awards must be supported by records that- support the distribution of salaries and wages among specific activities, while reflecting the total activity of the employee, not to exceed 100% of compensated activities. Cause: Wages requested for reimbursement in September 2024 reflected the wages paid in August 2024 in error and were not detected during the review process over the reimbursement request. Effect: Personnel costs charged to the award were based on amounts exceeding 100% of the employee’s compensation for one month, resulting in an overcharge to the award. Recommendation: Review of costs allocated and requested for reimbursement should incorporate consideration of the period the costs were incurred. Views of Responsible Officials and Planned Corrective Action: We acknowledge the finding and have strengthened our review process for reimbursement requests to prevent similar errors. Finance staff verify payroll periods against reimbursement periods before submission, and supervisors perform an additional review. This process includes careful cross-checking against the appropriate pay periods. This was an isolated occurrence with immaterial impact, but corrective steps will ensure accuracy in future requests.
2024-001 Compensation for Personal Services Head Start Cluster – Assistance Listing No. 93.600 Award Numbers: 08CH010736-06 – Award Period: December 1, 2023 through June 30, 2024 08CH012759-01 – Award Period: July 1, 2024 through November 30, 2024 MOEAI-202366770 – Award Period: July 1, 2023 through June 30, 2024 MOEAI-202474487 – Award Period: July 1, 2024 through June 30, 2025 Maternal, Infant and Early Childhood Home Visiting Grant – Assistance Listing No. 93.870 Award Numbers: CTGG1 QAAA 2024*2428 – Award Period: October 1, 2023 through September 30, 2024 CTGG1 QAAA 2025*2585 – Award Period: October 1, 2024 through September 30, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Condition: During our testing of time and effort records we noted that although timesheets were kept, they do not identify time spent working on different funding sources/cost objectives, so they were not used to calculate wages charged to the Federal awards tested. Instead, budgeted allocations were used, and the Organization could not support the allocation methodology(ies) applied to four out of the ten sampled employees. Criteria: According to 2 CFR Part 200.430(i)(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 (for IHE, this per the IHE's definition of IBS); (iv) Encompass federally-assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity's written policy; (v) Comply with the established accounting policies and practices of the non-Federal entity (See paragraph (h)(1)(ii) above for treatment of incidental work for IHEs.); and (vii) Support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. (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; C. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT (Continued) Criteria (Concluded): (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 adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated. Questioned Costs: Not determinable. Cause: The Organization did not document allocation methodology(ies) reflecting reasonable approximations of the activity actually performed for sampled employees in positions other than teachers and teaching assistants. Budget estimates were used for interim accounting purposes, however, there was no documented process to perform periodic after-the-fact reviews of interim charges nor adjustments made to ensure final amounts charged were properly allocated. Effect: Costs for salaries and wages were not fully supported by documentation in accordance with 2 CFR Part 200.430. Allowable costs could potentially be overpaid or underpaid or disallowed and required to be paid back to the Federal awarding agency (and/or pass-through entity). Recommendation: The Organization should strengthen policies and procedures to support a system of internal control which provides a reasonable assurance that the charges to Federal awards for salaries and wages are accurate, allowable, and properly allocated. This might include: 1. Enhance timesheet tracking to charge actual time spent working on different funding sources/cost objectives, or 2. Establishing a process to periodically review after-the-fact interim charges made to Federal awards based on budget estimates, make timely adjustments to ensure final amounts charged to Federal awards are accurate, allowable, and properly allocated, and document their reconciliation. Views of Responsible Officials and Planned Corrective Actions: Family Star acknowledges the FY24 finding related to labor allocation. During that fiscal year, the organization experienced several operational challenges, including insufficient documentation and oversight of labor allocation reporting. These administrative issues were contributing factors in a broader leadership restructuring, which included the elimination of five middle management positions. As a result, responsibilities for labor allocation were reassigned to ensure proper oversight. Since that time, Family Star has taken intentional steps to strengthen internal controls and improve the accuracy and consistency of key administrative functions. Labor time reporting is now aligned with organizational slot distribution across programs and funding sources to ensure compliance and transparency moving forward. To further reinforce accountability, we have implemented a new monthly monitoring procedure. On the first Wednesday of each month, the Senior Director of Community Partnerships and the HR Specialist jointly review and archive labor allocation records. This process ensures allocations are preserved, updates are made in a timely and compliant manner, and labor costs are supported by accurate documentation. These measures are designed to increase transparency, enhance internal controls, and ensure labor allocations are properly managed going forward.
2024-001 Compensation for Personal Services Head Start Cluster – Assistance Listing No. 93.600 Award Numbers: 08CH010736-06 – Award Period: December 1, 2023 through June 30, 2024 08CH012759-01 – Award Period: July 1, 2024 through November 30, 2024 MOEAI-202366770 – Award Period: July 1, 2023 through June 30, 2024 MOEAI-202474487 – Award Period: July 1, 2024 through June 30, 2025 Maternal, Infant and Early Childhood Home Visiting Grant – Assistance Listing No. 93.870 Award Numbers: CTGG1 QAAA 2024*2428 – Award Period: October 1, 2023 through September 30, 2024 CTGG1 QAAA 2025*2585 – Award Period: October 1, 2024 through September 30, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Condition: During our testing of time and effort records we noted that although timesheets were kept, they do not identify time spent working on different funding sources/cost objectives, so they were not used to calculate wages charged to the Federal awards tested. Instead, budgeted allocations were used, and the Organization could not support the allocation methodology(ies) applied to four out of the ten sampled employees. Criteria: According to 2 CFR Part 200.430(i)(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 (for IHE, this per the IHE's definition of IBS); (iv) Encompass federally-assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity's written policy; (v) Comply with the established accounting policies and practices of the non-Federal entity (See paragraph (h)(1)(ii) above for treatment of incidental work for IHEs.); and (vii) Support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. (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; C. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT (Continued) Criteria (Concluded): (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 adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated. Questioned Costs: Not determinable. Cause: The Organization did not document allocation methodology(ies) reflecting reasonable approximations of the activity actually performed for sampled employees in positions other than teachers and teaching assistants. Budget estimates were used for interim accounting purposes, however, there was no documented process to perform periodic after-the-fact reviews of interim charges nor adjustments made to ensure final amounts charged were properly allocated. Effect: Costs for salaries and wages were not fully supported by documentation in accordance with 2 CFR Part 200.430. Allowable costs could potentially be overpaid or underpaid or disallowed and required to be paid back to the Federal awarding agency (and/or pass-through entity). Recommendation: The Organization should strengthen policies and procedures to support a system of internal control which provides a reasonable assurance that the charges to Federal awards for salaries and wages are accurate, allowable, and properly allocated. This might include: 1. Enhance timesheet tracking to charge actual time spent working on different funding sources/cost objectives, or 2. Establishing a process to periodically review after-the-fact interim charges made to Federal awards based on budget estimates, make timely adjustments to ensure final amounts charged to Federal awards are accurate, allowable, and properly allocated, and document their reconciliation. Views of Responsible Officials and Planned Corrective Actions: Family Star acknowledges the FY24 finding related to labor allocation. During that fiscal year, the organization experienced several operational challenges, including insufficient documentation and oversight of labor allocation reporting. These administrative issues were contributing factors in a broader leadership restructuring, which included the elimination of five middle management positions. As a result, responsibilities for labor allocation were reassigned to ensure proper oversight. Since that time, Family Star has taken intentional steps to strengthen internal controls and improve the accuracy and consistency of key administrative functions. Labor time reporting is now aligned with organizational slot distribution across programs and funding sources to ensure compliance and transparency moving forward. To further reinforce accountability, we have implemented a new monthly monitoring procedure. On the first Wednesday of each month, the Senior Director of Community Partnerships and the HR Specialist jointly review and archive labor allocation records. This process ensures allocations are preserved, updates are made in a timely and compliant manner, and labor costs are supported by accurate documentation. These measures are designed to increase transparency, enhance internal controls, and ensure labor allocations are properly managed going forward.
2024-001 Compensation for Personal Services Head Start Cluster – Assistance Listing No. 93.600 Award Numbers: 08CH010736-06 – Award Period: December 1, 2023 through June 30, 2024 08CH012759-01 – Award Period: July 1, 2024 through November 30, 2024 MOEAI-202366770 – Award Period: July 1, 2023 through June 30, 2024 MOEAI-202474487 – Award Period: July 1, 2024 through June 30, 2025 Maternal, Infant and Early Childhood Home Visiting Grant – Assistance Listing No. 93.870 Award Numbers: CTGG1 QAAA 2024*2428 – Award Period: October 1, 2023 through September 30, 2024 CTGG1 QAAA 2025*2585 – Award Period: October 1, 2024 through September 30, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Condition: During our testing of time and effort records we noted that although timesheets were kept, they do not identify time spent working on different funding sources/cost objectives, so they were not used to calculate wages charged to the Federal awards tested. Instead, budgeted allocations were used, and the Organization could not support the allocation methodology(ies) applied to four out of the ten sampled employees. Criteria: According to 2 CFR Part 200.430(i)(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 (for IHE, this per the IHE's definition of IBS); (iv) Encompass federally-assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity's written policy; (v) Comply with the established accounting policies and practices of the non-Federal entity (See paragraph (h)(1)(ii) above for treatment of incidental work for IHEs.); and (vii) Support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. (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; C. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT (Continued) Criteria (Concluded): (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 adjustment must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated. Questioned Costs: Not determinable. Cause: The Organization did not document allocation methodology(ies) reflecting reasonable approximations of the activity actually performed for sampled employees in positions other than teachers and teaching assistants. Budget estimates were used for interim accounting purposes, however, there was no documented process to perform periodic after-the-fact reviews of interim charges nor adjustments made to ensure final amounts charged were properly allocated. Effect: Costs for salaries and wages were not fully supported by documentation in accordance with 2 CFR Part 200.430. Allowable costs could potentially be overpaid or underpaid or disallowed and required to be paid back to the Federal awarding agency (and/or pass-through entity). Recommendation: The Organization should strengthen policies and procedures to support a system of internal control which provides a reasonable assurance that the charges to Federal awards for salaries and wages are accurate, allowable, and properly allocated. This might include: 1. Enhance timesheet tracking to charge actual time spent working on different funding sources/cost objectives, or 2. Establishing a process to periodically review after-the-fact interim charges made to Federal awards based on budget estimates, make timely adjustments to ensure final amounts charged to Federal awards are accurate, allowable, and properly allocated, and document their reconciliation. Views of Responsible Officials and Planned Corrective Actions: Family Star acknowledges the FY24 finding related to labor allocation. During that fiscal year, the organization experienced several operational challenges, including insufficient documentation and oversight of labor allocation reporting. These administrative issues were contributing factors in a broader leadership restructuring, which included the elimination of five middle management positions. As a result, responsibilities for labor allocation were reassigned to ensure proper oversight. Since that time, Family Star has taken intentional steps to strengthen internal controls and improve the accuracy and consistency of key administrative functions. Labor time reporting is now aligned with organizational slot distribution across programs and funding sources to ensure compliance and transparency moving forward. To further reinforce accountability, we have implemented a new monthly monitoring procedure. On the first Wednesday of each month, the Senior Director of Community Partnerships and the HR Specialist jointly review and archive labor allocation records. This process ensures allocations are preserved, updates are made in a timely and compliant manner, and labor costs are supported by accurate documentation. These measures are designed to increase transparency, enhance internal controls, and ensure labor allocations are properly managed going forward.
Finding 2024.004: Activities Allowed or Unallowed - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program, COVID-19 Grants for New and Expanded Services under the Health Center Program. Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00132-2022 and 2023 Criteria According to 2 CFR, Part 200.430(i)(1) charges to Federal awards for salaries and wages must be based on records that accurately reflect the actual work performed, which must, among other things: (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) and reasonably reflect the total activity for which the employee is compensated by the non-Federal entity. Condition Charges to Federal Awards for salaries and wages were not supported by properly approved timesheets that agreed to payroll registers. Cause The Center's internal controls over payroll were not consistently followed. Effect or Potential Effect Unallowable expenses could be charged to the grant. Questioned Costs None. Context Out of the 25 payroll transactions selected for testing, we noted one instance in which the timesheet did not agree to the payroll register. Identification as a Repeat Finding Yes - Finding 2023.002. Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will implement additional controls to ensure payroll expenditures are being formally reviewed and approved.
Finding 2024-001 (Considered a significant deficiency in control compliance for allowable costs and activities) Federal Agency: United Stated Department of Health and Human Services Assistance Listing Numbers: 93.558, 17.258, 17.259, 17.278 Criteria: The Code of Federal Regulations (CFR), particularly 2 CFR § 200.430 (Compensation - Personal Services), requires that charges to federal awards for personnel costs must be based on accurate timekeeping records, and that those records should be properly mapped and reviewed to ensure costs are correctly allocated. Federal award recipients must have sufficient internal controls in place to ensure accurate billing to grants and proper review of payroll data, including verifying the proper mapping of timesheets to funding sources. Condition: For 2 out of 25 transactions for Temporary Assistance for Needy Families and 1 out of 25 transactions for Work Innovation and Opportunity Act Cluster, time reported by a sample of employees on their timesheets for work performed on the grant was not accurately mapped when imported into the payroll system. Specifically, the timesheets showed the amount of time employees spent working on the federal grant, but when this data was entered into the payroll system for processing, it was incorrectly allocated across other funding sources. Cause: The misallocation of time was caused by a failure in the internal controls related to the mapping process between timesheets and the payroll system. Specifically, the integration process between the timesheet reporting system and the payroll system did not correctly map time worked on federal grants to the appropriate funding sources. This error was not identified by the Organization's internal review controls. Effect: As a result of the mapping error, the Organization charged excess costs to the federal grant, leading to overbilling for labor costs. Questioned Costs: Known - $173. Recommendation: The Organization should review and adjust the mapping process between timesheet data and the payroll system to ensure that time worked on the federal grant is properly allocated. This may include updating software interfaces or implementing manual checks to ensure correct mapping. Management's View: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future.
Finding 2024-001 (Considered a significant deficiency in control compliance for allowable costs and activities) Federal Agency: United Stated Department of Health and Human Services Assistance Listing Numbers: 93.558, 17.258, 17.259, 17.278 Criteria: The Code of Federal Regulations (CFR), particularly 2 CFR § 200.430 (Compensation - Personal Services), requires that charges to federal awards for personnel costs must be based on accurate timekeeping records, and that those records should be properly mapped and reviewed to ensure costs are correctly allocated. Federal award recipients must have sufficient internal controls in place to ensure accurate billing to grants and proper review of payroll data, including verifying the proper mapping of timesheets to funding sources. Condition: For 2 out of 25 transactions for Temporary Assistance for Needy Families and 1 out of 25 transactions for Work Innovation and Opportunity Act Cluster, time reported by a sample of employees on their timesheets for work performed on the grant was not accurately mapped when imported into the payroll system. Specifically, the timesheets showed the amount of time employees spent working on the federal grant, but when this data was entered into the payroll system for processing, it was incorrectly allocated across other funding sources. Cause: The misallocation of time was caused by a failure in the internal controls related to the mapping process between timesheets and the payroll system. Specifically, the integration process between the timesheet reporting system and the payroll system did not correctly map time worked on federal grants to the appropriate funding sources. This error was not identified by the Organization's internal review controls. Effect: As a result of the mapping error, the Organization charged excess costs to the federal grant, leading to overbilling for labor costs. Questioned Costs: Known - $173. Recommendation: The Organization should review and adjust the mapping process between timesheet data and the payroll system to ensure that time worked on the federal grant is properly allocated. This may include updating software interfaces or implementing manual checks to ensure correct mapping. Management's View: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future.
Finding 2024-001 (Considered a significant deficiency in control compliance for allowable costs and activities) Federal Agency: United Stated Department of Health and Human Services Assistance Listing Numbers: 93.558, 17.258, 17.259, 17.278 Criteria: The Code of Federal Regulations (CFR), particularly 2 CFR § 200.430 (Compensation - Personal Services), requires that charges to federal awards for personnel costs must be based on accurate timekeeping records, and that those records should be properly mapped and reviewed to ensure costs are correctly allocated. Federal award recipients must have sufficient internal controls in place to ensure accurate billing to grants and proper review of payroll data, including verifying the proper mapping of timesheets to funding sources. Condition: For 2 out of 25 transactions for Temporary Assistance for Needy Families and 1 out of 25 transactions for Work Innovation and Opportunity Act Cluster, time reported by a sample of employees on their timesheets for work performed on the grant was not accurately mapped when imported into the payroll system. Specifically, the timesheets showed the amount of time employees spent working on the federal grant, but when this data was entered into the payroll system for processing, it was incorrectly allocated across other funding sources. Cause: The misallocation of time was caused by a failure in the internal controls related to the mapping process between timesheets and the payroll system. Specifically, the integration process between the timesheet reporting system and the payroll system did not correctly map time worked on federal grants to the appropriate funding sources. This error was not identified by the Organization's internal review controls. Effect: As a result of the mapping error, the Organization charged excess costs to the federal grant, leading to overbilling for labor costs. Questioned Costs: Known - $173. Recommendation: The Organization should review and adjust the mapping process between timesheet data and the payroll system to ensure that time worked on the federal grant is properly allocated. This may include updating software interfaces or implementing manual checks to ensure correct mapping. Management's View: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future.
Finding 2024-001 (Considered a significant deficiency in control compliance for allowable costs and activities) Federal Agency: United Stated Department of Health and Human Services Assistance Listing Numbers: 93.558, 17.258, 17.259, 17.278 Criteria: The Code of Federal Regulations (CFR), particularly 2 CFR § 200.430 (Compensation - Personal Services), requires that charges to federal awards for personnel costs must be based on accurate timekeeping records, and that those records should be properly mapped and reviewed to ensure costs are correctly allocated. Federal award recipients must have sufficient internal controls in place to ensure accurate billing to grants and proper review of payroll data, including verifying the proper mapping of timesheets to funding sources. Condition: For 2 out of 25 transactions for Temporary Assistance for Needy Families and 1 out of 25 transactions for Work Innovation and Opportunity Act Cluster, time reported by a sample of employees on their timesheets for work performed on the grant was not accurately mapped when imported into the payroll system. Specifically, the timesheets showed the amount of time employees spent working on the federal grant, but when this data was entered into the payroll system for processing, it was incorrectly allocated across other funding sources. Cause: The misallocation of time was caused by a failure in the internal controls related to the mapping process between timesheets and the payroll system. Specifically, the integration process between the timesheet reporting system and the payroll system did not correctly map time worked on federal grants to the appropriate funding sources. This error was not identified by the Organization's internal review controls. Effect: As a result of the mapping error, the Organization charged excess costs to the federal grant, leading to overbilling for labor costs. Questioned Costs: Known - $173. Recommendation: The Organization should review and adjust the mapping process between timesheet data and the payroll system to ensure that time worked on the federal grant is properly allocated. This may include updating software interfaces or implementing manual checks to ensure correct mapping. Management's View: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future.
Finding 2024-001 (Considered a significant deficiency in control compliance for allowable costs and activities) Federal Agency: United Stated Department of Health and Human Services Assistance Listing Numbers: 93.558, 17.258, 17.259, 17.278 Criteria: The Code of Federal Regulations (CFR), particularly 2 CFR § 200.430 (Compensation - Personal Services), requires that charges to federal awards for personnel costs must be based on accurate timekeeping records, and that those records should be properly mapped and reviewed to ensure costs are correctly allocated. Federal award recipients must have sufficient internal controls in place to ensure accurate billing to grants and proper review of payroll data, including verifying the proper mapping of timesheets to funding sources. Condition: For 2 out of 25 transactions for Temporary Assistance for Needy Families and 1 out of 25 transactions for Work Innovation and Opportunity Act Cluster, time reported by a sample of employees on their timesheets for work performed on the grant was not accurately mapped when imported into the payroll system. Specifically, the timesheets showed the amount of time employees spent working on the federal grant, but when this data was entered into the payroll system for processing, it was incorrectly allocated across other funding sources. Cause: The misallocation of time was caused by a failure in the internal controls related to the mapping process between timesheets and the payroll system. Specifically, the integration process between the timesheet reporting system and the payroll system did not correctly map time worked on federal grants to the appropriate funding sources. This error was not identified by the Organization's internal review controls. Effect: As a result of the mapping error, the Organization charged excess costs to the federal grant, leading to overbilling for labor costs. Questioned Costs: Known - $173. Recommendation: The Organization should review and adjust the mapping process between timesheet data and the payroll system to ensure that time worked on the federal grant is properly allocated. This may include updating software interfaces or implementing manual checks to ensure correct mapping. Management's View: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future.
Finding 2024-001 (Considered a significant deficiency in control compliance for allowable costs and activities) Federal Agency: United Stated Department of Health and Human Services Assistance Listing Numbers: 93.558, 17.258, 17.259, 17.278 Criteria: The Code of Federal Regulations (CFR), particularly 2 CFR § 200.430 (Compensation - Personal Services), requires that charges to federal awards for personnel costs must be based on accurate timekeeping records, and that those records should be properly mapped and reviewed to ensure costs are correctly allocated. Federal award recipients must have sufficient internal controls in place to ensure accurate billing to grants and proper review of payroll data, including verifying the proper mapping of timesheets to funding sources. Condition: For 2 out of 25 transactions for Temporary Assistance for Needy Families and 1 out of 25 transactions for Work Innovation and Opportunity Act Cluster, time reported by a sample of employees on their timesheets for work performed on the grant was not accurately mapped when imported into the payroll system. Specifically, the timesheets showed the amount of time employees spent working on the federal grant, but when this data was entered into the payroll system for processing, it was incorrectly allocated across other funding sources. Cause: The misallocation of time was caused by a failure in the internal controls related to the mapping process between timesheets and the payroll system. Specifically, the integration process between the timesheet reporting system and the payroll system did not correctly map time worked on federal grants to the appropriate funding sources. This error was not identified by the Organization's internal review controls. Effect: As a result of the mapping error, the Organization charged excess costs to the federal grant, leading to overbilling for labor costs. Questioned Costs: Known - $173. Recommendation: The Organization should review and adjust the mapping process between timesheet data and the payroll system to ensure that time worked on the federal grant is properly allocated. This may include updating software interfaces or implementing manual checks to ensure correct mapping. Management's View: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future.
Finding 2024-001 (Considered a significant deficiency in control compliance for allowable costs and activities) Federal Agency: United Stated Department of Health and Human Services Assistance Listing Numbers: 93.558, 17.258, 17.259, 17.278 Criteria: The Code of Federal Regulations (CFR), particularly 2 CFR § 200.430 (Compensation - Personal Services), requires that charges to federal awards for personnel costs must be based on accurate timekeeping records, and that those records should be properly mapped and reviewed to ensure costs are correctly allocated. Federal award recipients must have sufficient internal controls in place to ensure accurate billing to grants and proper review of payroll data, including verifying the proper mapping of timesheets to funding sources. Condition: For 2 out of 25 transactions for Temporary Assistance for Needy Families and 1 out of 25 transactions for Work Innovation and Opportunity Act Cluster, time reported by a sample of employees on their timesheets for work performed on the grant was not accurately mapped when imported into the payroll system. Specifically, the timesheets showed the amount of time employees spent working on the federal grant, but when this data was entered into the payroll system for processing, it was incorrectly allocated across other funding sources. Cause: The misallocation of time was caused by a failure in the internal controls related to the mapping process between timesheets and the payroll system. Specifically, the integration process between the timesheet reporting system and the payroll system did not correctly map time worked on federal grants to the appropriate funding sources. This error was not identified by the Organization's internal review controls. Effect: As a result of the mapping error, the Organization charged excess costs to the federal grant, leading to overbilling for labor costs. Questioned Costs: Known - $173. Recommendation: The Organization should review and adjust the mapping process between timesheet data and the payroll system to ensure that time worked on the federal grant is properly allocated. This may include updating software interfaces or implementing manual checks to ensure correct mapping. Management's View: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future.