Finding 1230003 (2025-005)

Material Weakness Repeat Finding
Requirement
B
Questioned Costs
-
Year
2025
Accepted
2026-09-16
Audit: 411216
Organization: Papa Ola Lokahi (HI)
Auditor: KKDLY LLC

AI Summary

  • Core Issue: The Organization failed to consistently retain documentation proving contractor performance as required by federal regulations.
  • Impacted Requirements: Noncompliance with the Uniform Guidance §200.334, which mandates retention of financial and supporting documents for three years.
  • Recommended Follow-Up: Establish clear policies and procedures to ensure proper documentation of contractor performance is collected and retained in line with contract terms.

Finding Text

Material Weakness Finding No. 2025-005: Document Retention U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Federal Assistance Listing Number 93.243. U.S. Department of Health and Human Services Health Care for Native Hawaiians Federal Assistance Listing Number 93.932. Criteria Pursuant to Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, “Financial records, supporting documents, statistical records, and all other non-Federal records must be retained for a period of three years from the date of submission of the final expenditure report…” Condition We noted that the Organization did not consistently retain documentation substantiating contractor performance of services was in accordance with the terms and conditions of the contract. However we noted that the Organization made efforts subsequent to the fiscal year to obtain documentation substantiating contractor performance. Cause The Organization’s policies and procedures do not include specific requirements to ensure that pertinent supporting documents are obtained and retained to evidence contractor performance of services pursuant to Federal requirements. Effect The lack of supporting documents for contractor expenditures as stipulated by Uniform Guidance could result in noncompliance of Federal record retention policies by the Organization.Recommendation We again recommend that the Organization incorporate policies and procedures to ensure the maintenance of adequate documentation to support contractor performance of services pursuant to contract terms. Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Financial records, supporting documents, statistical records, and all other non-Federal records must be retained for a period of three years from the date of submission of the final expenditure report…”, and recommendation made. The Organization further refers to the corrective action plan of Finding No. 2025-002: Subrecipient Monitoring, which describes the Organization’s implemented changes re: Subrecipient Monitoring and Management, Retroactive Subrecipient Portfolio Risk Assessment and Correction(s), and Subrecipient Policies and Procedures. For the year ended June 30, 2025, to the period of the audit report date, the Organization continued the prospective implementation of the above policies and processes, including the following reflective contract review work by the Organization: A. Contractor Performance Collection and Substantiation – November 2024 Incorporated specific review procedures to ensure the timely collection and substantiation of contractor performance deliverables (e.g., products, goods, services, activities, reports), consistent with the terms and conditions of the contract. B. Reviewed all contracts executed between July 1, 2024 to June 30, 2025. C. Discussed with respective program director(s), the implementation of initiation, consideration, decision, documentation and monitoring phased activities. D. Worked with respective program director(s) to document in memorandum(s) to file (MTF), the basis for decision and documentation on a contract-by-contract basis. E. Initiated work with respective program contract monitors to implement and document consistent Organization wide contract monitoring processes and activities (e.g., contract, term, billing, deliverables, eligible expenditures, data input, frequency). Although as of June 30, 2025 the implementation of the resolution was not completed, the implementation continues and is expected to be fully implemented by the next audit report date.

Corrective Action Plan

Material Weakness Finding No. 2025-005: Document Retention Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Financial records, supporting documents, statistical records, and all other non-Federal records must be retained for a period of three years from the date of submission of the final expenditure report…”, and recommendation made. The Organization further refers to the corrective action plan of Finding No. 2025-002: Subrecipient Monitoring, which describes the Organization’s implemented changes re: Subrecipient Monitoring and Management, Retroactive Subrecipient Portfolio Risk Assessment and Correction(s), and Subrecipient Policies and Procedures. For the year ended June 30, 2025, to the period of the audit report date, the Organization continued the prospective implementation of the above policies and processes, including the following reflective contract review work by the Organization: A. Contractor Performance Collection and Substantiation – November 2024. Incorporated specific review procedures to ensure the timely collection and substantiation of contractor performance deliverables (e.g., products, goods, services, activities, reports), consistent with the terms and conditions of the contract. B. Reviewed all contracts executed between July 1, 2024 to June 30, 2025. C. Discussed with respective program director(s), the implementation of initiation, consideration, decision, documentation and monitoring phased activities. D. Worked with respective program director(s) to document in memorandum(s) to file (MTF), the basis for decision and documentation on a contract-by-contract basis. E. Initiated work with respective program contract monitors to implement and document consistent Organization wide contract monitoring processes and activities (e.g., contract, term, billing, deliverables, eligible expenditures, data input, frequency). Although as of June 30, 2025 the implementation of the resolution was not completed, the implementation continues and is expected to be fully implemented by the next audit report date. Finding No. 2025-005: Document Retention Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations, and Sylvia Hussey, Ed.D. Chief of Staff.

Categories

Subrecipient Monitoring

Other Findings in this Audit

  • 1229985 2025-002
    Material Weakness Repeat
  • 1229986 2025-003
    Material Weakness Repeat
  • 1229987 2025-004
    Material Weakness Repeat
  • 1229988 2025-005
    Material Weakness Repeat
  • 1229989 2025-006
    Material Weakness Repeat
  • 1229990 2025-002
    Material Weakness Repeat
  • 1229991 2025-003
    Material Weakness Repeat
  • 1229992 2025-004
    Material Weakness Repeat
  • 1229993 2025-005
    Material Weakness Repeat
  • 1229994 2025-006
    Material Weakness Repeat
  • 1229995 2025-002
    Material Weakness Repeat
  • 1229996 2025-003
    Material Weakness Repeat
  • 1229997 2025-004
    Material Weakness Repeat
  • 1229998 2025-005
    Material Weakness Repeat
  • 1229999 2025-006
    Material Weakness Repeat
  • 1230000 2025-002
    Material Weakness Repeat
  • 1230001 2025-003
    Material Weakness Repeat
  • 1230002 2025-004
    Material Weakness Repeat
  • 1230004 2025-006
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.932 NATIVE HAWAIIAN HEALTH CARE SYSTEMS $8.06M
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $3.01M
84.362A NATIVE HAWAIIAN EDUCATION $443,816
93.837 CARDIOVASCULAR DISEASES RESEARCH $134,292
93.387 NATIONAL AND STATE TOBACCO CONTROL PROGRAM $94,036
93.859 BIOMEDICAL RESEARCH AND RESEARCH TRAINING $53,544
93.110 SPECIAL PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $24,603
93.185 IMMUNIZATION RESEARCH, DEMONSTRATION, PUBLIC INFORMATION AND EDUCATION TRAINING AND CLINICAL SKILLS IMPROVEMENT PROJECTS $17,998
93.307 NATIONAL AND STATE TOBACCO CONTROL PROGRAM $14,000
93.304 RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH $10,765
45.311 NATIVE AMERICAN AND NATIVE HAWAIIAN LIBRARY SERVICES $9,260
93.421 STRENGTHENING PUBLIC HEALTH SYSTEMS AND SERVICES THROUGH NATIONAL PARTNERSHIPS TO IMPROVE AND PROTECT THE NATION€™S HEALTH $6,000