Finding 1157927 (2024-001)

Material Weakness Repeat Finding
Requirement
ABLN
Questioned Costs
$1
Year
2024
Accepted
2025-09-30
Audit: 369958
Organization: Honorhealth (AZ)

AI Summary

  • Core Issue: Internal control deficiencies led to an overstatement of $1,406,446 in FEMA reimbursements due to expenditures not based on actual payments.
  • Impacted Requirements: Compliance with federal regulations on internal controls and accurate reporting of eligible costs as outlined in Title 2, Subtitle A, Chapter II, Part 200.
  • Recommended Follow-Up: Management should implement effective internal controls, refund questioned costs to FEMA, and conduct thorough reconciliations for future project applications.

Finding Text

Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, reporting, and special tests and provisions related to amounts reimbursed for the project worksheets. Identification of the federal program: Assistance Listing Number 97.036: • COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) • U.S. Department of Homeland Security • Federal award identification number: • Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers • Federal award year – January 20, 2020 to May 11, 2023 • Pass-through entity – Arizona Department of Emergency and Military Affairs Criteria or specific requirement (including statutory, regulatory or other citation): Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.303 Internal controls. The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The Office of Management and Budget Compliance Supplement states the Federal Emergency Management Agency (FEMA) evaluates the eligibility of all costs claimed by the applicant. Not all costs incurred as a result of the incident are eligible. Costs must be: • Directly tied to the performance of eligible work; • Adequately documented; • Reduced by all applicable credits, such as insurance proceeds and salvage values; • Authorized and not prohibited under federal, state, territorial, tribal, or local government laws or regulations; • Consistent with applicant’s internal policies, regulations, and procedures that apply uniformly to both federal awards and other activities of the applicant; and • Necessary and reasonable to accomplish the work properly and efficiently The Office of Management and Budget Compliance Supplement requires the entity to accurately complete the project application which is used to document the details of the applicant’s project and costs claimed. The Office of Management and Budget Compliance Supplement states the entity is required to certify that reported costs were incurred in performance of eligible work, that the approved work was completed, that the project is in compliance with the provisions of the FEMA-State Agreement, all grant conditions were met, and that payments for that project were made in accordance with the applicable payment provisions. Condition: During our testing over the expenditures included in the project worksheets, we observed management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheets were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Cause: Management did not have effective internal controls in place over the compliance requirements as stated in the criteria or specific requirement section above. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on actual paid expenditures which resulted in an overstatement of the amount reimbursed by FEMA. Without sufficient internal controls, other compliance matters could occur in the future. Questioned costs: $1,406,446 – Assistance Listing Number 97.036 – Federal award identification number – Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers Questioned costs were computed by calculating the difference between the expenditures submitted for reimbursement in the FEMA project worksheets and the actual paid expenditures. Context: During our testing over the expenditures included in the project worksheets, we obtained a listing of expenditures submitted for reimbursement to FEMA and selected a sample of 67 for testing the compliance requirements. There was 1 out of 67 selections where the expenditure reported for reimbursement was not based on actual paid expenditure. The sampling was a statistically valid sample. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Management’s control regarding the review of the project worksheet expenditures did not identify this matter when submitting the project worksheet for reimbursement to FEMA. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in the FEMA project worksheets are actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Views of responsible officials: Management concurs with the audit finding and has implemented a corrective action plan to address the identified issue. Management has notified Arizona DEMA of the identified expenditures and has begun the process of reimbursing the $1,406,446 to FEMA. For all future FEMA project applications, Management will conduct a comprehensive reconciliation process prior to submission. This process will include a detailed review of invoice documentation and verification of payment to ensure compliance with applicable federal requirements.

Corrective Action Plan

Federal Award Findings and Questioned Costs – Year ending December 31, 2024 Finding 2024-001 – Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, reporting, and special tests and provisions related to amounts reimbursed for the project worksheets. Identification of the federal program: Assistance Listing Number 97.036: • COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) • U.S. Department of Homeland Security • Federal award identification number: o Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers • Federal award year – January 20, 2020 to May 11, 2023 • Pass-through entity – Arizona Department of Emergency and Military Affairs (Arizona DEMA) Condition: During the testing over the expenditures included in the project worksheets, management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheets were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Cause: Management did not have effective internal controls in place over the compliance requirements as stated in the criteria or specific requirement section of the report. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on actual paid expenditures which resulted in an overstatement of the amount reimbursed by FEMA. Without sufficient internal controls, other compliance matters could occur in the future. Questioned costs: $1,406,446 – Assistance Listing Number 97.036 – Federal award identification number – Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers Questioned costs were computed by calculating the difference between the expenditures submitted for reimbursement in the FEMA project worksheets and the actual paid expenditures. Context: During the testing over the expenditures included in the project worksheets, the auditors obtained a listing of expenditures submitted for reimbursement to FEMA and selected a sample of 67 for testing the compliance requirements. There was 1 out of 67 selections where the expenditure reported for reimbursement was not based on actual paid expenditure. The sampling was a statistically valid sample. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Management’s control regarding the review of the project worksheet expenditures did not identify this matter when submitting the project worksheet for reimbursement to FEMA. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in the FEMA project worksheets are actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Views of responsible officials: Management concurs with the audit finding and has implemented a corrective action plan to address the identified issue. Management has notified Arizona DEMA of the identified expenditures and has begun the process of reimbursing the $1,406,446 to FEMA. For all future FEMA project applications, Management will conduct a comprehensive reconciliation process prior to submission. This process will include a detailed review of invoice documentation and verification of payment to ensure compliance with applicable federal requirements. Responsible Parties: Heather Mahoney, Network Controller Anticipated Date of Completion: September 30, 2025

Categories

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring Cash Management Eligibility Reporting Matching / Level of Effort / Earmarking

Programs in Audit

ALN Program Name Expenditures
97.036 Covid-19 - Disaster Grants - Public Assistance (presidentially Declared Disasters) $22.89M
10.568 Emergency Food Assistance Program (administrative Costs) $896,297
10.565 Commodity Supplemental Food Program $350,882
16.575 Crime Victim Assistance $161,371
64.U01 Veterans Home Based Primary Care $95,622
93.052 National Family Caregiver Support, Title Iii, Part E $64,985
97.024 Emergency Food and Shelter National Board Program $50,000
93.667 Social Services Block Grant $43,095
93.044 Special Programs for the Aging, Title Iii, Part B, Grants for Supportive Services and Senior Centers $39,081
16.560 National Institute of Justice Research, Evaluation, and Development Project Grants $17,402
93.393 Cancer Cause and Prevention Research $14,600
10.558 Child and Adult Care Food Program $12,205
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $3,412
10.575 Farm to School Grant Program $3,412