Finding 1226465 (2024-003)

Material Weakness Repeat Finding
Requirement
ABH
Questioned Costs
-
Year
2024
Accepted
2026-08-13

AI Summary

  • Core Issue: The Organization's records for Title V expenditures lack sufficient detail, making it impossible to verify compliance with federal requirements.
  • Impacted Requirements: Failure to meet documentation standards under Uniform Guidance 2 CFR § 200.302 and 2 CFR § 200.333 has led to a disclaimed opinion on compliance.
  • Recommended Follow-Up: Improve recordkeeping practices, implement a standardized tracking process for federal grants, and train staff on compliance requirements.

Finding Text

Finding 2024 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-003, 2022-003, and 2023-003) Material Weakness – 93.U01 Title V Criteria: Per Uniform Guidance 2 CFR § 200.302 and 2 CFR § 200.333, entities must maintain records that adequately identify the source and application of federal funds and retain documentation to support compliance with program requirements. Condition: The Organization’s general ledger did not allow for sufficient identification of transactions related to the major program, Title V. Title V expenditures were recorded through journal entries without supporting transaction-level detail. Because of this, the population of expenditures could not be tied to individual transactions, and pulling samples from this population would not provide a reasonable basis for drawing conclusions about the population tested. As a result, we were unable to select transactions for testing or perform the necessary audit procedures to assess compliance with federal requirements. Questioned Costs: Unable to determine due to scope limitation. Cause: Staff turnover and the Organization’s recordkeeping practices did not ensure sufficient documentation was maintained to support federal compliance. Effect: Due to the lack of adequate documentation, we were unable to obtain sufficient, appropriate audit evidence to form an opinion on the Organization’s compliance with these requirements. Consequently, a disclaimed opinion on compliance was issued for this major program. Additionally, these expenditures may be subject to repayment or further review by the granting agency. Recommendation: We recommend that management strengthen documentation and recordkeeping procedures to ensure compliance with federal record retention requirements. The Organization should implement a standardized process for tracking federal grant expenditures, ensuring proper coding within the accounting system, conduct periodic internal reviews to verify completeness and accuracy of financial records, and provide training to finance staff on Uniform Guidance requirements for grant record retention and reporting. Views of Responsible Officials: See the corrective action plan that accompanies the schedule of findings and questioned costs.

Corrective Action Plan

Finding 2024-003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Title V, C FDA 93. U0 1) Material Weakness (Repeat Finding: 2021-003, 2022-003, 2023-003) Condition: Title V expenditures were recorded through summary journal entries without transactionlevel detail, preventing the auditor from selecting a valid sample or testing compliance. A disclaimed opinion on compliance was issued for this major program. Questioned costs are undetermined due to scope limitation. Corrective Action: • Restructure the chart of accounts/ GL coding so every Title V transaction is individually recorded and traceable to source documentation, rather than aggregated into journal entries. • Require program/grant coding at the point of transaction entry (accounts payable, payroll allocation, purchasing) rather than after the fact. • Implement a quarterly internal review reconciling Title V ledger detail to the approved Title V budget and contract terms. • Provide finance staff training on Uniform Guidance recordkeeping requirements (2 CFR §200.302, §200.333) specific to federal award transactions. Responsible Party: Chief Financial Officer Anticipated Completion Date: GL restructuring to be implemented concurrent with the Organization's new fund accounting system (Blackbaud Financial Edge NXT), implementation kickoff August 13, 2026; complete by March 31, 2027, with the first fully traceable Title V transaction month in April 2027

Categories

Questioned Costs Allowable Costs / Cost Principles Material Weakness Period of Performance Reporting Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1226464 2024-003
    Material Weakness Repeat
  • 1226466 2024-004
    Material Weakness Repeat
  • 1226467 2024-004
    Material Weakness Repeat
  • 1226468 2024-005
    Material Weakness Repeat
  • 1226469 2024-005
    Material Weakness Repeat
  • 1226470 2024-006
    Material Weakness Repeat
  • 1226471 2024-006
    Material Weakness Repeat
  • 1226472 2024-007
    Material Weakness Repeat
  • 1226473 2024-007
    Material Weakness Repeat
  • 1226474 2024-008
    Material Weakness Repeat
  • 1226475 2024-008
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.U01 TITLE V, URBAN INDIAN HEALTH SERVICES $3.17M
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $431,850
93.653 INDIAN HEALTH SERVICE DOMESTIC VIOLENCE PREVENTION PROGRAMS $240,383
93.933 DEMONSTRATION PROJECTS FOR INDIAN HEALTH $208,333
93.391 ACTIVITIES TO SUPPORT STATE, TRIBAL, LOCAL AND TERRITORIAL (STLT) HEALTH DEPARTMENT RESPONSE TO PUBLIC HEALTH OR HEALTHCARE CRISES $150,078
93.332 COOPERATIVE AGREEMENT TO SUPPORT NAVIGATORS IN FEDERALLY-FACILITATED EXCHANGES $87,942
93.318 PROTECTING AND IMPROVING HEALTH GLOBALLY: BUILDING AND STRENGTHENING PUBLIC HEALTH IMPACT, SYSTEMS, CAPACITY AND SECURITY $30,465
93.800 ORGANIZED APPROACHES TO INCREASE COLORECTAL CANCER SCREENING $20,000
93.217 FAMILY PLANNING SERVICES $5,694