Finding Text
2023-102 Lack of Documentation Related to Reporting (prior two years 2022-108 and 2021-104) (initially reported 2018)
Assistance Listing Number: 93.224 and 93.527
Name of Federal Agency: Department of Health and Human Services, HRSA
Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program
Compliance Requirement: Reporting
Pass-through Entity: N/A
Federal Grant/Contract Number and Grant Year: H8006452 (2022 and 2023), H2E45500 (2022), COVID-19 ARP H8F40324 (2021), H8K49674 (2023), C1439909 (2020), H2E50094 (2023), COVID-19 H8L50549 (2023) and COVID-19 H8G48569 (2022)
Finding Type: Significant Deficiency in Internal Control
Questioned Costs: $0
Condition: The Organization did not maintain proper documentation in support of reporting requirements.
Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also, under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards.
Cause: Supporting records used to populate the Uniform Data System (UDS) report were not retained by the Organization.
Effect: The Organization could submit incorrect information.
Recommendation: Documentation should be prepared, reviewed, and retained to support the reporting. The documentation should clearly document who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate.
Views of Responsible Officials and Planned Corrective Action: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025.