Finding 484917 (2023-002)

Finding 2023-002 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.011 – COVID-19 – National Organizations for State and Local Officials Award Numbers: G32HS42634C6, U3SHS45317C6 Award Years: G32HS42634C6: 07/31/2021-5/31/2023: U3SHS45317C6: 11/1/2021-7/31/2023 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal” entity must: (a) Establish and maintain effective internal control 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the “Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Per Award Number G32HS42634‐01‐00 and U3SHS45317‐01‐00, Terms and Conditions Section, page 3, subsection 5, “As the grantee institution, you have the primary responsibility for developing and adhering to your organizational participant incentive policy and maintaining appropriate documentation for each participant gift card. Lastly, it is also the responsibility of the grant recipient to report all grant related costs and it is the responsibility of the sub-recipient to track and report these costs to you as the grant recipient.” Per management’s Gift Card Process – Community Impact – COVID 1 and COVID 2 Grants policy, Section 12, “During scheduled / clinic gift card pick up, the Community Health Worker collects the following information to ensure the gift card is exchanged to the prequalified client who had received prior education: Vaccine Card (ensure 2nd or booster shot is documented), form of ID with the client’s name on it to match with vaccine card and internal spreadsheet, and internal spreadsheet for final confirmation of communication and exchange.” Condition: Participants are eligible to participate in the program and receive a gift card if they received a COVID-19 vaccine. The Corporation screened applicants for eligibility; however, they did not retain supporting documentation to support that the participants in the program had a COVID-19 vaccine. Cause: The Corporation did not have internal controls in place to require supporting documentation be retained to support that the participant had a COVID-19 vaccination. Effect or potential effect: Participant may receive a gift card for participating in the program and not have received the COVID-19 vaccination. Questioned costs: $68,797 – represents the total amount of gift cards distributed in 2023 where documentation to support that the participant had a COVID-19 vaccination was not retained. Context: We selected a sample of 40 gift cards provided to participants in 2023 to perform eligibility testing in which we reviewed evidence of the disbursement and the participant’s attestations as required by the relevant grant agreements. However, the Corporation did not retain evidence that the participant had received a COVID-19 vaccination. The total gift cards provided to participants was $68,797. Federal expenditures reported in the schedule of expenditures of federal awards for Assistance Listing 93.011 totaled $1,586,209 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: Yes. Prior year finding 2022-003. Recommendation: The Corporation should revise its current internal controls to require proof of the participant’s COVID-19 vaccination. Views of responsible officials: Management agrees with the finding. G32HS42634C6 and U3SHS45317C6 ended on May 31, 2023 and July 31, 2023, respectively, and therefore the remediation of the internal controls related to these programs is no longer applicable. However, effective August 15, 2023, the Corporation has implemented the following changes, which we believe would address future internal control considerations. The below procedures were added to the grant checklist which is required on all grants applied for by Corporation entities. Responsible parties are required to document all procedures and sign off on these procedures. The requirements formalize reporting and data management procedures, which include proper management approval and retention of these records. The grant checklist is additionally approved by the grant applicant and Vice President or Executive Director overseeing the grant. Grant Checklist Items Initials and Date Completed Comments Determine if there are any eligibility requirements. If so, please list the requirements and how these requirements will be documented. • All eligibility requirements should be documented and signed off on at the time the eligibility is confirmed. • All documentation of these procedures should be retained and readily available upon request.