Finding 528722 (2024-001)

Significant Deficiency
Requirement
A
Questioned Costs
-
Year
2024
Accepted
2025-03-18
Audit: 346753
Auditor: Kpmg LLP

AI Summary

  • Core Issue: There was a lack of proper review and approval for Time and Effort Reporting, leading to incomplete submissions.
  • Impacted Requirements: This finding violates the compliance requirement for effective internal controls as outlined in 2 CFR 200.303.
  • Recommended Follow-up: Management should implement stronger review processes to ensure all time and effort reports are complete and properly certified.

Finding Text

(3)   Findings and Questioned Costs Relating to Federal Awards: Finding 2024 001 Lack of review and approval of Time and Effort Reporting Finding Type: Significant Deficiency Federal Program Name: Immunization Cooperative Agreements Federal Agency: U.S. Department of Health and Human Services ALN # and Program Expenditures: 93.268 ($688,344) Federal Award Year: N/A Questioned Costs: None Compliance Requirement: Activities Allowed or Unallowed Condition Found In performing the monthly time and effort reporting certification and sign-off, management had not established adequate internal controls to ensure the completeness of time and effort certification in accordance with federal regulations, resulting in 4 of 58 (6.9%) submissions missing staff attestations and 2 submissions missing attestation dates. Additionally, for February 2024 time and effort report, while the manager initialed the time and effort report spreadsheet for each attesting employee, their signature was missing to certify their review and approval of the overall monthly submission. Criteria Per 2 CFR 200.303, guidance requires non-Federal entities to, among other things, 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. Effective internal controls should include establishing and maintaining adequate controls over the certification of time and effort reporting required for the program. Cause Management did not have appropriate and sufficient review controls in place during the fiscal year to ensure the completeness of time and effort reporting attestation and certification. Possible Asserted Effect Failure to properly review and approve time and effort reports may result in inaccurate time and effort allocations being charged to the program. In this particular case, this did not occur as the employees did record their own hours and were 100% allocated to the specific grant. Repeat Finding No similar finding was reported in prior year audits. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Recommendation We recommend management review its current process for ensuring time and effort reporting attestation and certifications are properly reviewed and approved by the manager/supervisor before they are submitted to the Grant office and Finance. Views of Responsible Officials FTCH recognizes the observations made by KPMG, and has drafted a Corrective Action response.

Corrective Action Plan

Corrective Actions Relating to Federal Awards: Finding 2024 001 Lack of review and approval of Time and Effort Reporting Corrective Actions Manual processes will be reinforced regarding time and effort reporting (T/E) and Operations (Ops) will be instructed to hold each drawdown until all processes are completed and approved by the Grant Program Manager. Grant Program Manager will also conduct more frequent internal monitoring of completeness of records, and create an e-learning for all team members involved in the grant process regarding the steps that need to be followed. The Froedtert ThedaCare Health (FTCH) compliance team has created a proposal to implement a Grant Management Software solution. The software solution will have mechanisms for facilitating automated and streamlined processes to support time and effort documentation requirements. Specific actions to be taken include: Party Responsible Laurie Moore, Grant Program Manager Corrective Action Reinforce T/E and implement hold practice with each Ops owner expensing salaries Anticipated Completion Date April 1, 2025 Party Responsible Laurie Moore, Grant Program Manager Corrective Action Increase internal monitoring frequency for grants expensing salaries Anticipated Completion Date Beginning April 15, 2025 and ongoing thereafter Party Responsible Laurie Moore, Grant Program Manager Corrective Action Create e-learning Anticipated Completion Date Create Learning: May 1, 2025 Implementation: June 1, 2025 (If not able to do e-learn, will publish PowerPoint)

Categories

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Other Findings in this Audit

  • 1105164 2024-001
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.268 Immunization Cooperative Agreements $688,344
21.027 Coronavirus State and Local Fiscal Recovery Funds $250,699
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $198,234
93.399 Cancer Control $68,401
93.301 Small Rural Hospital Improvement Grant Program $38,750
93.426 The National Cardiovascular Health Program $15,056
93.241 State Rural Hospital Flexibility Program $6,273