2024-001 – Coronavirus State and Local Fiscal Recovery Funds – ALN No. 21.027 - Distribution of Compensation – Internal Controls over Allowable Costs and Activities (Significant Deficiency) Grant No. X50-8-018 Passed through Office of the Governor, Criminal Justice Coordinating Council Grant Period: October 1, 2023-September 30, 2025 Criteria: Under 2 CFR Section 200.303(a), non‐federal entities must establish and maintain effective internal controls to provide reasonable assurance that the entity is managing the federal awards in compliance with statues, regulations, and the terms and conditions of the award. Additionally, under 2 CFR Section 200.430(i) compensation records must support the distribution of the employee’s compensation among specific activities or costs objectives if the employee works on more than one Federal award and compensation of employees used in meeting cost sharing or matching requirements on Federal awards must be supported in the same manner. Condition: For specific payroll costs selected, the compensation records supporting the distribution of employees’ compensation to the federal award did not equal the amounts charged to the federal grant. Effect: The lack of controls to ensure the correct amounts are charged to the federal program based on the time and effort of the personnel could result in charging unallowable costs to the federal program. Cause: The Foundation calculated the amounts charged to the federal grant based on the budgeted percentage of time for each employee rather than the actual hours per the compensation records. Known Questioned Costs: $273 Likely Questioned Costs: $3,122 Perspective: This finding represents a systematic problem. Of the twenty-five transactions tested, five had errors. The sample was not statistically valid. Repeat Finding: No Recommendation: We recommend the Association establish policies and procedures to ensure that compensation is properly documented and distributed between Federal awards and properly approved.
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.
Coronavirus State and Local Recovery Funds - Assistance Listing Number 21.027; Pass-through from State of Geogia Office of the Governor and Dekalb County; Grant Period: Year Ended December 31, 2024 Condition: The auditor's testing of payroll allocations for employees charging time to Coronavirus State and Local Recovery Funds, passed through from the State of Georgia Office of the Governor, identified instances where the hours allocated to the grant award did not precisely match the hours recorded on the employees' approved contemporaneous timesheets. In a sample of 48 transactions, 41 instances showed minor discrepancies. The discepancies included both overallocations (more hours charged to the program than recorded on the timesheets) and underallocations (fewer hours charged than recorded). While the total variance for the sample was determined to be immaterial, the result indicated a systemic control weakness. Criteria: Under 2 CFR 200.430(g)(1), 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 that provides reasonable assurance that the charges are accurate, allowable, and properly allocated, and support the distribution of the employee's salary or wages among specific activities or costs objectives if the employee works on more than one federal award or a federal award and non-federal award. Cause: Management did not have sufficient internal controls or review procedures in place to ensure that the hours used for payroll allocation reconciled exactly to the source documentation (timesheets) on a consistent basis. The process relies on manual data entry, which was prone to minor errors, and did not include a robust, documented verification step. Effect: The Agency could potentially over or under allocate salaries and benefits to the program. Questioned Cost: None noted as a result of audit procedures performed. Recommendation: The Agency should implement a formal, documented monthly reconciliation process between the hours recorded on employee timesheets and the hours/percentages used for actual salary allocation to all federal awards. The entity should consider implementing an automated effort certification or time-tracking system to reduce manual errors and ensure consistency. Management Response: We agree with the findings in the audit report and have developed a Corrective Action Plan to address each item promptly. This has been a challenging year for the organization, including turnover in the Chief Financial Officer ("CFO") position and the fact that this was our first Single Audit due to increased federal funding related to COVID-19 programs. These factors contributed to delays in audit readiness, gaps in technical accounting for grants, and weaknesses in internal controls over financial reporting and federal award reporting. We have implemented a comprehensive plan to address these challenges and will be hiring a new CFO in the first quarter of 2026.
Findings 2024-005 – All Federal Programs – Significant Deficiency Type of Finding: Significant Deficiency in Internal Control over Compliance and Compliance – Allowable Costs (Payroll) Federal Agency: National Science Foundation Federal Program Name: Research and Development Cluster - NSF Technology, Innovation and Partnerships CO-WY Climate Resilience Engine Assistance Listing Number: 47.084 Federal Award Identification Number: 2315760 Award Period: March 1, 2024 – February 28, 2026 Criteria or specific requirement: Federal regulations require that charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. Per 2 CFR §200.430(i), payroll allocations must be supported by after-the-fact records of actual time worked rather than budget. Condition: It was noted through our testing that the Organization allocated salaries and wages to the program based on budgeted percentages rather than after-the-fact records of time and efforts expended by employees. Individuals whose time is fully charged to federal grants are also not required to provide time and effort reporting. Further, for one of the five individuals selected, the individual timesheet could not be located. Questioned costs: Unknown Context: Based on our testing of payroll, for the one individual out of five selected that had time allocated to multiple grants and programs, no time and effort reporting was available to support the allocation to the federal grant. There was also not a consistent process of reviewing and approving payroll time sheets and registers by management. There was also no time reporting required to support individuals that were fully charged to the grant. Cause: The Organization does not currently have a payroll system whereby individuals are required to record time and effort by program or grant. Allocations are entered into the system based on expected budgets for grant programs when individuals participate in more than one program. The payroll system also did not require payroll to be initiated and approved by separate individuals. Effect: As a result, there is an increased risk that payroll costs charged to the federal program do not accurately reflect the actual effort expended, which could result in unallowable costs being charged to the grant. This practice does not comply with federal requirements for documentation of personnel expenses. Repeat finding: No Recommendation: We recommend that the Organization implement procedures to ensure that payroll allocations to federal programs are supported by after-the-fact records of actual time worked, in accordance with 2 CFR part 200.430(i). The Organization should discontinue the use of budget estimates for payroll allocations and require contemporaneous documentation of time and effort for all employees whose salaries are charged to federal awards. Payroll should be initiated and reviewed by different individuals and the process should include a way to verify either manually or electronically that payroll was approved prior to processing. Views of responsible officials: There is no disagreement with the audit finding. See Corrective Action Plan.
Criteria: In accordance with 2 CFR 200.430, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. Budget estimates alone do not qualify as support for charges to Federal awards. Condition: For the year ended December 31, 2024, AEA did not maintain support for salary based on work performed. Salary and wages were charged based on a flat rate for all employees. Cause: The salaries and wages are not charged based on actual work performed. Effect: AEA is not in compliance with 2 CFR 200.430. Questioned Costs: None reported. Context: A random sampling of the federal expenditures. Repeat Finding: This finding was not corrected. See finding item 2023-101 in the prior year findings. Recommendation: We recommend that AEA establish a system to determine and document the time spent and amount charged to their programs. View of Responsible Officials: Refer to management’s corrective action plan.
Finding 2024- 007 – Timecard Approval Controls – Payroll Charge to Federal Grant, Significant Deficiency Federal award agency: US Department of Transportation Federal Transit Administration Program name and ALN: Federal Transit Cluster ALN 20.507 Federal Transit Formula Grants, ALN 20.525 State of Good Repair Grants Federal award identification number: IL-2017-028-00, IL-2018-024-00, IL-2019-022-01, IL-2021-050-00, IL-2022-005-01, IL-2022-032-00, IL-2023-036-01, IL-2024-025-00 Federal award year: 2017, 2018, 2019, 2022, 2023, 2024 Criteria: The Uniform Guidance requires non‑Federal entities to establish and maintain effective internal control over Federal awards that provides reasonable assurance that the entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award (2 CFR §200.303). In addition, payroll costs charged to Federal awards must be adequately supported and properly authorized to ensure that only allowable and accurate costs are charged (2 CFR §200.430(i)). Condition: During testing of payroll transactions charged to the Federal program, RSM identified instances in which employee timecards were not supported by evidence of timely supervisory review and approval. Specifically, for certain timecards tested, approval either could not be substantiated, occurred after fiscal year end, or lacked documentation evidencing the date of approval. Cause: Management did not consistently maintain documentation evidencing timely supervisory review and approval of employee timecards charged to Federal grants. Additionally, monitoring controls over the timeliness of timecard approvals were not sufficient to ensure compliance with established payroll control procedures. Effect or potential effect: Without timely supervisory approval of timecards, there is an increased risk that unallowable, inaccurate, or improperly allocated payroll costs could be charged to Federal awards. Questioned costs: None noted. Context: 16 control exceptions out of 60 selections. The sample was not intended to be, and was not, a statistically valid sample. Recommendation: RSM recommends that management strengthen internal controls over payroll charged to Federal grants by ensuring that all employee timecards are reviewed and approved by supervisors in a timely manner and that documentation evidencing the approval date is retained. Management should also implement periodic monitoring to verify compliance with timecard approval requirements. Views of responsible officials: Management acknowledges the finding and agrees that remediation is necessary. Management will implement the recommendations that it has defined within the corrective action plan required by Title 2 CFR 200.511(c) executed on April 16, 2026.
Finding 2024-002, Timesheet – Timekeeping (Assistance Listings 19.510, 93.566, 93.583 and 93.576) Criteria: 2 CFR § 200.430 requires that the distribution of salary and wages charged to federal awards be based on actual employee activity as reflected in personnel activity reports (timesheets), prepared after-the-fact, and includes the total activity for which employees were compensated. Condition and Context: The Organization does not maintain functional timesheets and/or other documentation of the allocation of hours worked by program. Cause: Internal controls over the accurate distribution of hours on the timesheets were not operating effectively or designed properly. Effect: This lack of documented time and allocation limits the Organization’s ability to demonstrate how personnel costs are distributed across its programs and funding sources. Identification as a repeat finding: Yes. Questioned costs: None. Recommendation: We recommend that the Organization strengthen its policies and procedures for the timekeeping and distribution of the employees’ hours in accordance with the requirements of the federal programs. View of responsible officials: Management has reviewed the finding, noting the inherent complexity of time allocation in our operational environment. Because our personnel routinely serve multiple clients simultaneously across various federal grants, tracking exact hours per case presents a significant administrative challenge. Furthermore, the delayed receipt of the FY23 audit-delivered post-FY24-precluded the implementation of procedural adjustments during the audited timeframe. To address our operational realities and ensure strict, ongoing adherence to 2 CFR § 200.430, the Organization immediately instituted systemic enhancements for FY25. The Organization has transitioned all time tracking to a streamlined, system-driven process within our UKG platform: • Integrated UKG Time Tracking and Approvals: All employees are now required to punch in and out directly through the UKG system, efficiently assigning their actual hours worked to specific program and grant codes to generate functional, after-the-fact timesheets. To further streamline this documentation, the Organization is gradually transitioning our existing supervisory reviews into UKG’s electronic sign-off workflow, which will centralize our approval records and ensure accurate distribution across federal awards. By standardizing time tracking in UKG and refining our approval process, the Organization has alleviated the manual tracking burden on our staff while maintaining an audit-ready system to resolve this finding.
Assistance Listing Number(s): 10.902 Name of Federal Program or Cluster: Soil and Water Conservation Name of Federal Agency: Department of Agriculture Award Periods: Grant # NR205F48XXXXC006 and period September 30, 2020 through September 30, 2025 and Grant # FAN NR223A750022C002 and period December 21, 2023 through September 30, 2025 Assistance Listing Number(s): 10.912 Name of Federal Program or Cluster: Environmental Quality Incentives Program Name of Federal Agency: Department of Agriculture Award Periods: Grant # NR205F48XXXXC006 and period September 30, 2020 through September 30, 2025 and Grant # FAN NR223A750022C002 and period December 21, 2023 through September 30, 2025 Assistance Listing Number(s): 10.924 Name of Federal Program or Cluster: Conservation Stewardship Program Name of Federal Agency: Department of Agriculture Award Periods: Grant # NR205F48XXXXC006 and period September 30, 2020 through September 30, 2025 and Grant # FAN NR223A750022C002 and period December 21, 2023 through September 30, 2025 Criteria or Specific Requirement: Subparts D and E of 2 CFR Part 200 require a nonfederal entity to establish written policies, procedures, and standards of conduct, including procedures to implement the cash management requirements of 2 CFR section 200.305, procedures that comply with the procurement standards of 2 CFR sections 200.318 through 200.326, and procedures for determining the allowability of costs in accordance with Subpart E of 2 CFR Part 200. Specifically, 2 CFR sections 200.430, 200.431, and 200.475 require written policies. Condition: There are no written policies and procedures for allowable costs/cost principles, cash management, procurement and suspension and debarment requirements. Cause: The Organization does not have a process for reviewing their accounting policies and procedures manual on a regular basis to ensure written procedures conform to Uniform Guidance requirements. Effect or Potential Effect: A lack of written policies, procedures, and standards of conduct may result in noncompliance with the requirements of federal programs and/or disallowed costs. Repeat Finding: Yes Recommendation: We recommend the Organization’s written policies and procedures be reviewed and updated for compliance with Uniform Guidance. he organization should become familiar with the requirements of Subparts D and E of 2 CFR Part 200 and establish appropriate written policies, procedures, and standards of conduct. Views of Responsible Officials: Management agrees with the finding and they will evaluate our findings to determine an appropriate corrective action. Financial policies and procedures will be created and implemented. Annual schedule of expenditures will be created by Executive Director or Bookkeeper and reviewed by Board of Directors.
U. S. Department of Health and Human Services 2024-002 Allowable Costs Program(s) Name of Federal Program (Assistance Listing Number) Urban Indian Health Services (93.193) Special Diabetes Program for Indians - Diabetes Prevention and Treatment Projects (93.237) Criteria - Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non-Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services for the programs identified above. Context and Condition - We selected 41 paychecks from several pay periods to test for compliance with standards in these two programs. Records for eight of the paychecks tested lacked documentation of approval of the employee’s supervisor. Cause - The Organization replaced its payroll processing servicer subsequent to 2024. Access to certain records from the prior servicer were no longer available. Personnel turnover resulting in inconsistencies in maintaining required documentation. Effect - A federal program could be charged compensation for employees who did not provide services directly attributable to the program or charged for goods/services not related to the program. Questioned Costs - No costs were questioned. Repeat finding - Yes Statistically valid - Yes Recommendation - We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job-costing system implemented. Views of responsible officials - The Organization believes the paychecks identified were approved prior to payment. We will ensure that documentation is downloaded each pay period to ensure such documentation is not lost when a change in servicer is made.
2024-002 PAYROLL TIMESHEET REVIEW AND APPROVAL Federal Agency:U.S. Department of Health and Human Services Federal Program Title & Assistance Listing Number: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Type of Finding: Significant Deficiency and Other Non-compliance Compliance Area: Allowable Costs Questioned Costs: None Condition During our testing of 55 payroll transactions charged to the SAMHSA program, we identified the following exceptions: 1. One of 55 sampled payroll transactions had two inconsistent timesheets. One timesheet was a signed PDF showing 13 hours, while an unsigned Excel timesheet showed 25 hours. The employee was paid based on the 25 hours reflected in the unsigned Excel timesheet. The timesheet used to process payroll did not contain the required manager’s approval; therefore, UVNR could not demonstrate supervisory approval of the hours paid. 2. One of 55 sampled payroll transactions contained a clerical error in the calculation of total hours. The timesheet reflected a total of 12 hours; however, the correct total was 14 hours. The error resulted in the employee being underpaid by two hours, and no subsequent correction was requested or processed. Criteria Title 2 CFR § 200.430 requires charges to Federal awards for salaries and wages to be based on records that accurately reflect the work performed. Such records must be supported by a system of internal control that provides reasonable assurance that personnel costs are accurate, allowable, and properly allocated to the Federal award. UVNR’s payroll control also requires timesheets and applicable leave records to be reviewed and approved by appropriate personnel before payroll is processed. Effect UVNR could not demonstrate that all hours paid and charged to the Federal program were supported by properly reviewed and approved time records. In addition, the clerical error resulted in an employee underpayment that was not subsequently corrected. Failure to maintain consistent review and approval procedures increases the risk that payroll expenses charged to Federal programs may be inaccurate, unsupported, improperly allocated, or result in employee overpayments or underpayments. Cause UVNR did not consistently ensure that the final timesheet used to process payroll was reviewed and approved. Additionally, the payroll review process did not include an adequate independent verification of timesheet calculations or a formal procedure to identify, document, and correct payroll discrepancies.
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.