Finding 1187057 (2025-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-03-26

AI Summary

  • Core Issue: Significant deficiency in training compliance for the Maternal, Infant and Early Childhood Home Visiting Program, with 16% and 20% of employees failing to complete required HIPAA and Civil Rights training, respectively.
  • Impacted Requirements: Non-compliance with 2 CFR 200.303, which mandates effective internal controls over federal awards to ensure compliance with federal regulations.
  • Recommended Follow-Up: Enhance internal controls by implementing a tracking system for training compliance, assign responsibility for oversight, and consider a rolling-year training schedule for better management.

Finding Text

B. Major Federal Program Findings and Questioned Costs 2025-001 Failure to Properly Complete Required Training – Significant Deficiency Federal Program – Maternal, Infant and Early Childhood Home Visiting Program CFDA 93.870 Pass-through Entity – Community Based Care Federal Agency – United States Department of Health and Human Services Criteria: 2 CFR 200.303 states a non-Federal entity must establish and maintain effective internal controls 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. Condition: During our audit, auditors tested 25 employees for completion certificate of required training as a condition of the grants. Two of the required annual training were significantly non-compliant. • The Annual HIPPA Training 4 of the 25 (16%) of employees did not properly complete the training. • The Annual 504/Civil Rights Training 5 of the 25 (20%) of the employees did not properly complete the training. Questioned Costs: No questioned costs were noted. Cause: The cause of this condition appears to be a lack of oversight in monitoring training completion records and insufficient internal controls over training compliance. Effect: Failure to properly complete required training increases the risk of noncompliance with federal program requirements, potentially leading to disallowed costs, penalties, or other adverse consequences. Recommendation: We recommend that management, enhance internal controls over training compliance by implementing more effective tracking and monitoring system and assign responsibility for ensuring timely completion of required training to a specific individual or department. Additionally, we recommend Hibiscus consider implementing a rolling-year training schedule rather than an annual hire-date renewal process. This approach can streamline tracking, reduce administrative burdens, and ensure consistent compliance by aligning training requirements with a standard cycle applicable to all employees.

Corrective Action Plan

Management Response: All staff will be required to complete annual trainings during the same time each year. This has already been implemented for the current fiscal year FY25-26. Tracking of staff trainings will be maintained monthly and filed in staff personnel files by a Human Resources staff.

Categories

Subrecipient Monitoring Internal Control / Segregation of Duties Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.658 FOSTER CARE_TITLE IV-E $513,551
93.870 MATERNAL, INFANT AND EARLY CHILDHOOD HOME VISITING GRANT $210,160
93.556 PROMOTING SAFE AND STABLE FAMILIES $151,606
16.575 CRIME VICTIM ASSISTANCE $114,018
93.659 ADOPTION ASSISTANCE $2,677
93.667 SOCIAL SERVICES BLOCK GRANT $569