Finding 555670 (2021-003)

Material Weakness Repeat Finding
Requirement
A
Questioned Costs
-
Year
2021
Accepted
2025-04-23
Audit: 354288
Organization: Island Health, Inc. (MA)
Auditor: Cohnreznick LLP

AI Summary

  • Core Issue: Inadequate internal controls over payroll and nonpayroll expenditures led to unapproved payrates and discrepancies in timesheets.
  • Impacted Requirements: Non-compliance with 2 CFR, Part 200.430(i)(1) and 2 CFR 200.40.3(g) regarding accurate documentation and approval processes.
  • Recommended Follow-Up: Enforce consistent internal controls to ensure all payroll and nonpayroll expenditures are properly reviewed and approved by supervisors.

Finding Text

Finding 2021-003: Activities Allowed or Unallowed - Material Weakness Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS26638 - 2020 and 2021, H8DCS35487 - 2020, H8CCS34364 - 2020, H8ECS38373 - 2020, and H8F40829 - 2021 Criteria In accordance with 2 CFR, Part 200.430(i)(1), charges to Federal awards for salaries and wages must be based on records that accurately reflect the actual work performed, which must, among other things: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) and reasonably reflect the total activity for which the employee is compensated by the non-Federal entity. Additionally, costs must be adequately documented, as per 2 CFR 200.40.3(g). Condition Charges to Federal Awards for salaries and wages were not supported by properly approved payrates, and timesheets did not agree to payroll registers. Additionally, nonpayroll expenditures were not supported by proper approval. Cause The Center's internal controls over payroll were not consistently followed to ensure payrates were approved and timesheets agreed to payroll registers. Additionally, the Center's internal controls over nonpayroll expenditures were not consistently followed to ensure that expenditures were approved. Effect Failure to ensure accurate wage and allocation of employee's time across programs could result in non-compliance with the grant requirements or unallowable costs being charged. Additionally, failure to ensure accurate nonpayroll expenditures could result in non-compliance with the grant requirements or unallowable costs being charged. Questioned Costs None. Context We selected 25 payroll transactions charged to the federal program for testing. Out of the 25 transactions tested, we noted 21 instances where there was no formal approval of payrates and where they were not appropriately reflected in the payroll registers, 15 instances where timecards were not appropriately reflected in the payroll registers, and all 25 labor reports showed no formal approval documented. Additionally, for nonpayroll allowable costs, out of five transactions tested, we noted five instances where there was no formal approval showing review that the cost was allowable under the program. Identification of Repeat Finding Yes, see finding 2020-003. Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the timesheet and payrates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently reinforces its internal controls over nonpayroll expenditures to ensure all expenditures were approved by the appropriate supervisor. Views of Responsible Officials Management and the Board of Directors agree with the finding and will implement additional controls to ensure all expenditures have evidence of formal approval of review.

Corrective Action Plan

Item 2021.003 – Activities Allowed or Unallowed Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the timesheet and payrates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently reinforces its internal controls over nonpayroll expenditures to ensure all expenditures were approved by the appropriate supervisor. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: Timesheet and payrate review and approval: • Standardize timesheet submission and approval process. • Utilize and electronic timesheet system to document the verification of employee payrates and ensure there is a detailed audit trail that records all submissions, review, and approval by supervisors. • Conduct regular audits to verify timesheets and payrates are reviewed and approved by supervisors. Nonpayroll Expenditures: • Evaluate and improve upon existing processes to ensure internal control over nonpayroll expenditures are working. This includes enforcement of approval policies with mandatory documentation and regular monitoring throughout the process for a clear audit trail. • Conduct regular audits to verify nonpayroll expenditures have been reviewed and approved by supervisors.

Categories

Allowable Costs / Cost Principles

Other Findings in this Audit

  • 555671 2021-004
    Material Weakness Repeat
  • 555672 2021-005
    Material Weakness Repeat
  • 555673 2021-006
    Material Weakness Repeat
  • 555674 2021-007
    Material Weakness Repeat
  • 555675 2021-003
    Material Weakness Repeat
  • 555676 2021-004
    Material Weakness Repeat
  • 555677 2021-005
    Material Weakness Repeat
  • 555678 2021-006
    Material Weakness Repeat
  • 555679 2021-007
    Material Weakness Repeat
  • 555680 2021-003
    Material Weakness Repeat
  • 555681 2021-004
    Material Weakness Repeat
  • 555682 2021-005
    Material Weakness Repeat
  • 555683 2021-006
    Material Weakness Repeat
  • 555684 2021-007
    Material Weakness Repeat
  • 1132112 2021-003
    Material Weakness Repeat
  • 1132113 2021-004
    Material Weakness Repeat
  • 1132114 2021-005
    Material Weakness Repeat
  • 1132115 2021-006
    Material Weakness Repeat
  • 1132116 2021-007
    Material Weakness Repeat
  • 1132117 2021-003
    Material Weakness Repeat
  • 1132118 2021-004
    Material Weakness Repeat
  • 1132119 2021-005
    Material Weakness Repeat
  • 1132120 2021-006
    Material Weakness Repeat
  • 1132121 2021-007
    Material Weakness Repeat
  • 1132122 2021-003
    Material Weakness Repeat
  • 1132123 2021-004
    Material Weakness Repeat
  • 1132124 2021-005
    Material Weakness Repeat
  • 1132125 2021-006
    Material Weakness Repeat
  • 1132126 2021-007
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $1.03M
93.224 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care $600,236
93.498 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $29,517
93.461 Covid-19-Claims Reimbursement for the Uninsured Program and the Covid-19 Coverage Assistance Fund $12,720