Finding 1203107 (2025-004)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2025
Accepted
2026-03-30

AI Summary

  • Core Issue: The Organization lacks adequate internal controls to maintain supporting documentation for the UDS report, risking inaccuracies.
  • Impacted Requirements: Compliance with federal requirements for submitting complete and accurate UDS reports to HRSA.
  • Recommended Follow-Up: Establish a robust review process for reports, ensuring all supporting records are reconciled and verified before submission.

Finding Text

Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Centers Cluster Assistance Listing Number: 93.224 and 93.527 Federal Award Identification Number: H80CS00824-23-11 Award Periods: May 1, 2024 – April 30, 2025 Type of Finding: Significant deficiency in internal control over compliance Criteria: The Organization is required to submit an annual Uniform Data System (UDS) report to HRSA that is complete, accurate, and supported by underlying records. Per federal requirements, the auditee is responsible for establishing and maintaining effective internal controls over compliance, including controls to ensure the accuracy and completeness of reports submitted to federal agencies. Condition: During our audit procedures, we noted the Organization did not have adequate internal controls related to maintaining supporting documentation for all of the key tables included within the UDS report. Questioned Costs: None. Context: The Organization submitted its annual UDS report, which includes multiple data tables derived from various systems and sources, including billing, electronic health records, and financial records. During our testing, the Organization was not able to provide the necessary documentation to support the amounts reported in Table 8A Lines 1 & 3. Cause: The condition appears to be due to turnover within the finance department and not maintaining the necessary supporting documentation used to prepare the UDS report as filed. Effect: Without adequate controls over reporting, there is an increased risk that reports submitted to the federal awarding agency may be inaccurate or incomplete, which could impact funding, compliance, and federal oversight. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review reports prior to submission including the reconciliations and underlying records that support the amounts in the report.

Corrective Action Plan

Reporting Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review reports prior to submission including the reconciliations and underlying records that support the amounts in the report. Action taken in response to finding: An internal audit and review of the UDS reporting supporting files will be implemented as of April 1, 2026 to ensure accuracy of the documentation and calculations. Name(s) of the contact person(s) responsible for corrective action: John Robinson, CFO Planned completion date for corrective action plan: April 1, 2026 and it will continue moving forward.

Categories

Internal Control / Segregation of Duties Reporting Significant Deficiency

Other Findings in this Audit

  • 1203105 2025-002
    Material Weakness Repeat
  • 1203106 2025-003
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $1.80M
93.224 HEALTH CENTER PROGRAM (COMMUNITY HEALTH CENTERS, MIGRANT HEALTH CENTERS, HEALTH CARE FOR THE HOMELESS, AND PUBLIC HOUSING PRIMARY CARE) $276,096
93.354 PUBLIC HEALTH EMERGENCY RESPONSE: COOPERATIVE AGREEMENT FOR EMERGENCY RESPONSE: PUBLIC HEALTH CRISIS RESPONSE $79,960
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $25,000