Finding 1179028 (2023-011)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2023
Accepted
2026-03-12

AI Summary

  • Core Issue: Late submission of federal financial reports due to inadequate monitoring and documentation.
  • Impacted Requirements: Compliance with federal reporting deadlines as per Uniform Guidance (2 CFR §200.328).
  • Recommended Follow-Up: Strengthen internal controls by tracking reporting deadlines, implementing supervisory reviews, and formalizing turnover procedures.

Finding Text

Federal Agency: U. S. Department of Health and Human Services Cluster: Health Centers Clusters AL No.: 93.224 & 93.527 Program Title: Community Health Centers & Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program Area: Reporting Repeat Finding from Prior Audit? Yes Finding Type: Material Weakness in Internal Control over Compliance Questioned Cost: $0.00 Criteria: Under Uniform Guidance (2 CFR §200.328), non-federal entities are required to submit complete, accurate, and timely financial and performance reports in accordance with federal award terms and conditions. Condition: The following SF-425, Federal Financial Reports for the reporting period ended March 31, 2023, were submitted after the required deadline of 90 days following the reporting period end date: AL No. Grant No. Reporting Date Date Submitted 93.224 21H8FCS41048C6 3/31/2023 7/27/2023 93.224 22H80CS31624 3/31/2023 8/3/2023 93.527 23H8GCS48480 11/30/2023 4/3/2024 Cause: Federal reporting requirements, including SF-425 and Uniform Data System (UDS) reporting, were not adequately monitored, documented, or retained. This condition was exacerbated by significant turnover in accounting and executive management and the absence of a formal turnover of federal reporting responsibilities and supporting records. Effect: Late submission of required federal financial reports and the absence of required UDS reporting documentation limit Kagman Community Health Center, Inc.’s ability to demonstrate compliance with federal reporting requirements. Recommendation: Kagman Community Health Center, Inc. should strengthen internal controls over federal reporting by: 1. Establishing procedures to track and monitor all federal financial and special reporting requirements, including SF-425 deadlines. 2. Implementing supervisory review procedures to verify the accuracy, completeness, and timeliness of federal reports prior to submission. 3. Establishing formal turnover and documentation procedures to ensure continuity of federal reporting responsibilities during personnel changes. Views of the Officials: Kagman Community Health Center, Inc.’s response is documented in the corrective action plan.

Corrective Action Plan

Corrective Action Plan Action Item Responsible Party Timeline Monitoring Establish procedures to track and monitor all federal reporting deadlines, including SF-425 and UDS reports. CFO Immediate Monthly review Maintain supporting documentation for federal financial and program reports in accordance with record-retention policies. CFO / Accounting Staff Immediate Periodic internal review Implement supervisory review procedures to verify the accuracy and timeliness of federal reports prior to submission. CFO / Executive Management Immediate Each reporting cycle Establish formal turnover procedures for federal reporting responsibilities to ensure continuity of reporting and documentation during personnel transitions. CFO Within 30 days Management oversight ________________________________________ Management Response Management, under the direction of the Chief Financial Officer, acknowledges the findings related to the timeliness of federal financial reporting. Management recognizes that the late submission of certain SF-425 reports resulted from prior turnover in accounting and executive management personnel and the absence of formal procedures for monitoring federal reporting deadlines and maintaining supporting documentation. As of FY2026, management implemented supervisory oversight and a personnel exit clearance process to ensure continuity and completeness of financial records. Management also provides the Board with updates on personnel transitions and associated risks to support proper oversight and timely remediation of identified issues. As of FY2026, procedures have been implemented requiring that all supporting documentation and attachments be uploaded and maintained within the online accounting system and google shared drive to strengthen internal controls, improve transparency, and ensure consistent documentation practices.

Categories

Reporting

Other Findings in this Audit

  • 1179022 2023-006
    Material Weakness Repeat
  • 1179023 2023-007
    Material Weakness Repeat
  • 1179024 2023-008
    Material Weakness Repeat
  • 1179025 2023-009
    Material Weakness Repeat
  • 1179026 2023-010
    Material Weakness Repeat
  • 1179027 2023-011
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 HEALTH CENTER PROGRAM (COMMUNITY HEALTH CENTERS, MIGRANT HEALTH CENTERS, HEALTH CARE FOR THE HOMELESS, AND PUBLIC HOUSING PRIMARY CARE) $2.49M
93.225 NATIONAL RESEARCH SERVICE AWARDS HEALTH SERVICES RESEARCH TRAINING $139,026
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $72,668