Finding 1176789 (2025-002)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2025
Accepted
2026-03-06
Audit: 390662
Auditor: BAKER TILLY

AI Summary

  • Core Issue: Timely submission of required reports for federal grants was not met, with seven out of eleven selected reports submitted late due to inadequate controls.
  • Impacted Requirements: Federal reporting criteria for Head Start, Medicaid, and Aging clusters were violated, affecting compliance with grant agreements.
  • Recommended Follow-Up: Implement stronger controls and a two-level review process for report preparation to ensure all reports are submitted on time.

Finding Text

FINDING 2025-002 – Reporting; Significant Deficiency in Internal Control over Compliance Head Start Cluster Medicaid Cluster Aging Cluster Assistance Listing Numbers: 93.600, 93.778, 93.044, 93.045, 93.053 Federal Program Names: Head Start, Grants to States for Medicaid, Special Programs for the Aging - Tile III, Part B - Grants for Supportive Services and Senior Centers, Special Programs for the Aging - Tile III, Part C, Nutrition Services, and Nutrition Services Incentive Program Award Years: Various Criteria: In accordance with federal reporting requirements a variety of different types of reports are required for compliance relating to each of the grants, such as SF-425 reports, SF-429, special reports, and performance reports are required to be prepared and submitted on an annual basis. Condition and context: Of the sixty-seven reports filed during the year, we selected eleven reports and noted that seven reports were not submitted timely as required by the grant agreements as a result of the lack of segregation of duties and procedures surrounding deadlines. The following selections were reported late by program: • Head Start Cluster (ALN 93.600) – For one of the one financial report selected, the report was submitted 10 days late. • Medicaid Cluster (ALN 93.778) – For two of the four reports selected, one report was one day late, and the other was four days late. • Aging Cluster (ALN 93.044, 93.045, 93.053) – For four of the six monthly and quarterly performance reports selected, reports was submitted 3 to 15 days late. Questioned costs: None. Effect: The Organization was not timely with reporting requirements of the grants. Cause: Controls were not operating as designed to ensure the timely submission of the reports required were filed by the due dates as a result of the lack of segregation of duties and procedures surrounding deadlines. Repeat finding: Yes 2024-003. Recommendation: We recommend the Organization implement controls to ensure timely submission of required reports. We recommend the Organization improve existing review controls in the reporting process to ensure timely submission. Views of responsible officials and planned corrective actions: Management agrees with the assessment. To address this repeat finding, management has revised its approach to reporting oversight by implementing full department-level responsibility for report preparation, review, and submission. Each department is responsible for maintaining its own reporting timeline in accordance with grant and contract requirements. Departments have clarified internal roles and responsibilities for report preparation, review, and submission. All reports required by contract must be submitted timely and must include two levels of documented review. Reports will be reviewed by the preparer’s Director (or their designee); if the Director is the preparer, the review will be conducted by the Chief Operating Officer or in their absence, the Chief Executive Officer. All financial reports required by contract must have documented review by a member of the fiscal department. Report backup documentation and proof of timely submission must be retained by the department.

Corrective Action Plan

FINDING 2025-002 - Reporting Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment. To address this repeat finding, management has revised its approach to reporting oversight by implementing full department-level responsibility for report preparation, review, and submission. Each department is responsible for maintaining its own reporting timeline in accordance with grant and contract requirements. Departments have clarified internal roles and responsibilities for report preparation, review, and submission. All reports required by contract must be submitted timely and must include two levels of documented review. Reports will be reviewed by the preparer’s Director (or their designee); if the Director is the preparer, the review will be conducted by the Chief Operating Officer or in their absence, the Chief Executive Officer. All financial reports required by contract must have documented review by a member of the fiscal department. Report backup documentation and proof of timely submission must be retained by the department. Departments will ensure that staff involved in reporting are knowledgeable of applicable requirements and deadlines. Management will conduct periodic reviews at the executive level to confirm that reporting controls are operating as revised and that required reports are submitted timely in accordance with grant agreements. Management expects significant improvement in reporting for the fiscal year ending in 2026. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller

Categories

Reporting Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1176759 2025-002
    Material Weakness Repeat
  • 1176760 2025-002
    Material Weakness Repeat
  • 1176761 2025-002
    Material Weakness Repeat
  • 1176762 2025-002
    Material Weakness Repeat
  • 1176763 2025-002
    Material Weakness Repeat
  • 1176764 2025-002
    Material Weakness Repeat
  • 1176765 2025-002
    Material Weakness Repeat
  • 1176766 2025-002
    Material Weakness Repeat
  • 1176767 2025-002
    Material Weakness Repeat
  • 1176768 2025-002
    Material Weakness Repeat
  • 1176769 2025-002
    Material Weakness Repeat
  • 1176770 2025-002
    Material Weakness Repeat
  • 1176771 2025-002
    Material Weakness Repeat
  • 1176772 2025-002
    Material Weakness Repeat
  • 1176773 2025-002
    Material Weakness Repeat
  • 1176774 2025-002
    Material Weakness Repeat
  • 1176775 2025-002
    Material Weakness Repeat
  • 1176776 2025-002
    Material Weakness Repeat
  • 1176777 2025-002
    Material Weakness Repeat
  • 1176778 2025-002
    Material Weakness Repeat
  • 1176779 2025-002
    Material Weakness Repeat
  • 1176780 2025-002
    Material Weakness Repeat
  • 1176781 2025-002
    Material Weakness Repeat
  • 1176782 2025-002
    Material Weakness Repeat
  • 1176783 2025-002
    Material Weakness Repeat
  • 1176784 2025-002
    Material Weakness Repeat
  • 1176785 2025-002
    Material Weakness Repeat
  • 1176786 2025-002
    Material Weakness Repeat
  • 1176787 2025-002
    Material Weakness Repeat
  • 1176788 2025-002
    Material Weakness Repeat
  • 1176790 2025-003
    Material Weakness Repeat
  • 1176791 2025-003
    Material Weakness Repeat
  • 1176792 2025-003
    Material Weakness Repeat
  • 1176793 2025-003
    Material Weakness Repeat
  • 1176794 2025-003
    Material Weakness Repeat
  • 1176795 2025-003
    Material Weakness Repeat
  • 1176796 2025-003
    Material Weakness Repeat
  • 1176797 2025-003
    Material Weakness Repeat
  • 1176798 2025-003
    Material Weakness Repeat
  • 1176799 2025-003
    Material Weakness Repeat
  • 1176800 2025-003
    Material Weakness Repeat
  • 1176801 2025-003
    Material Weakness Repeat
  • 1176802 2025-003
    Material Weakness Repeat
  • 1176803 2025-003
    Material Weakness Repeat
  • 1176804 2025-003
    Material Weakness Repeat
  • 1176805 2025-003
    Material Weakness Repeat
  • 1176806 2025-003
    Material Weakness Repeat
  • 1176807 2025-003
    Material Weakness Repeat
  • 1176808 2025-003
    Material Weakness Repeat
  • 1176809 2025-003
    Material Weakness Repeat
  • 1176810 2025-003
    Material Weakness Repeat
  • 1176811 2025-003
    Material Weakness Repeat
  • 1176812 2025-003
    Material Weakness Repeat
  • 1176813 2025-003
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
10.569 EMERGENCY FOOD ASSISTANCE PROGRAM (FOOD COMMODITIES) $527,836
10.766 COMMUNITY FACILITIES LOANS AND GRANTS $398,765
17.278 WIOA DISLOCATED WORKER FORMULA GRANTS $390,428
10.415 RURAL RENTAL HOUSING LOANS $380,423
16.575 CRIME VICTIM ASSISTANCE $364,825
14.239 HOME INVESTMENT PARTNERSHIPS PROGRAM $268,388
10.561 STATE ADMINISTRATIVE MATCHING GRANTS FOR THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM $248,573
93.600 HEAD START $191,770
10.565 COMMODITY SUPPLEMENTAL FOOD PROGRAM $154,734
93.569 COMMUNITY SERVICES BLOCK GRANT $146,176
93.568 LOW-INCOME HOME ENERGY ASSISTANCE $127,507
14.228 COMMUNITY DEVELOPMENT BLOCK GRANTS/STATE'S PROGRAM AND NON-ENTITLEMENT GRANTS IN HAWAII $91,004
10.558 CHILD AND ADULT CARE FOOD PROGRAM $88,959
81.042 WEATHERIZATION ASSISTANCE FOR LOW-INCOME PERSONS $84,575
10.182 PANDEMIC RELIEF ACTIVITIES: LOCAL FOOD PURCHASE AGREEMENTS WITH STATES, TRIBES, AND LOCAL GOVERNMENTS $79,093
81.999 BONNEVILLE POWER ADMINISTRATION/LIEE PROGRAM $78,008
17.258 WIOA ADULT PROGRAM $74,844
93.671 FAMILY VIOLENCE PREVENTION AND SERVICES/DOMESTIC VIOLENCE SHELTER AND SUPPORTIVE SERVICES $73,547
93.044 SPECIAL PROGRAMS FOR THE AGING, TITLE III, PART B, GRANTS FOR SUPPORTIVE SERVICES AND SENIOR CENTERS $72,034
93.495 COMMUNITY HEALTH WORKERS FOR PUBLIC HEALTH RESPONSE AND RESILIENT $58,842
10.568 EMERGENCY FOOD ASSISTANCE PROGRAM (ADMINISTRATIVE COSTS) $47,416
10.665 SCHOOLS AND ROADS - GRANTS TO STATES $32,970
10.218 BUILDINGS AND FACILITIES PROGRAM $30,300
93.323 EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ELC) $28,948
93.052 NATIONAL FAMILY CAREGIVER SUPPORT, TITLE III, PART E $24,535
93.045 SPECIAL PROGRAMS FOR THE AGING, TITLE III, PART C, NUTRITION SERVICES $21,001
10.177 REGIONAL FOOD SYSTEM PARTNERSHIPS $20,815
93.497 FAMILY VIOLENCE PREVENTION AND SERVICES/ SEXUAL ASSAULT/RAPE CRISIS SERVICES AND SUPPORTS $14,873
93.391 EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ELC) $14,582
10.187 THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) COMMODITY CREDIT CORPORATION ELIGIBLE RECIPIENT FUNDS $13,754
17.259 WIOA YOUTH ACTIVITIES $13,687
16.588 VIOLENCE AGAINST WOMEN FORMULA GRANTS $11,364
93.778 MEDICAL ASSISTANCE PROGRAM $10,889
93.558 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES $5,789
10.194 COMMODITY CREDIT CORPORATION (CCC) FUNDING TO ALLEVIATE EMERGENCY SUPPLY CHAIN DISRUPTION IN THE COMMODITY SUPPLEMENTAL FOOD PROGRAM (CSFP) $3,908
93.053 NUTRITION SERVICES INCENTIVE PROGRAM $3,880