Finding 573259 (2023-004)

Significant Deficiency
Requirement
ABH
Questioned Costs
-
Year
2023
Accepted
2025-08-11

AI Summary

  • Core Issue: Supervisors did not consistently sign off on timesheets, which undermines the primary control over employee time entry and billing for federal grants.
  • Impacted Requirements: This lack of oversight violates compliance standards set by 2 CFR 200.400 and 45 CFR 75.303, risking inaccurate time entries and reimbursement requests.
  • Recommended Follow-Up: Ensure all timesheets are signed by supervisors immediately after review; implement a process to return unsigned timesheets for approval before reimbursement requests are submitted.

Finding Text

System of Internal Controls Over Compliance for Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: State of Nevada Federal Program: Block Grants for Community Mental Health Services (AL# 93.958); Block Grants for Prevention and Treatment of Substance Abuse (AL# 93.959) Criteria: In accordance with 2 CFR 200.400 and 45 CFR 75.303, the Organization is responsible for effective administration of federal awards through sound management practices, to include effective internal controls over supporting documentation for cost allocations. Condition: A primary control over employee time entry and subsequent billing to grants is the review and approval of bimonthly timesheets by supervisors, and this review and approval is indicated by the supervisor signing the timesheet. During our testing, we noted that the signature of supervisors indicating this review was absent from 8 of the 64 timesheets tested for Block Grants for Community Mental Health Services, AL# 93.958 and 11 of the 68 timesheets tested for Block Grants for Prevention and Treatment of Substance Abuse, AL# 93.959. These grants had multiple duplicate employees tested between the two grants. Total unduplicated findings were that the signature of supervisors indicating this review was absent from 11 of the 88 unduplicated timesheets selected, indicating this primary control was not operating effectively during the year. Cause: Digital signatures were utilized during the fiscal year that, at times, did not save properly. Timesheets were not re-reviewed or re-signed if they did not save properly. While a compensating control existed whereby the overall expenditures were reviewed during the request for reimbursement process prior to submission, the primary control was not consistently evidenced. Effect: Lack of indication of review and approval of timesheets could cause inaccurate time entry and inaccurate requests for reimbursements to be processed. Recommendation: We recommend that all timesheets are signed by a supervisor immediately after their review and approval to ensure documentation of the control exists and to ensure timesheet accuracy. We further recommend that, if timesheets with no signature are noted during the request for reimbursement process, they be returned to the supervisor for review and signature prior to the request for reimbursement being submitted. Views of Responsible Officials and Planned Corrective Actions: As of April 2024, the organization implemented a new electronic timekeeping system (SwipeClock) in partnership with a third-party payroll provider. This system includes: • Supervisor approval of all time entries. • A final review by a member of the executive team (CEO, Operations Manager, or Accounting Coordinator). This three-tiered approval process ensures accuracy and accountability in payroll allocation to federal grants.

Corrective Action Plan

Corrective Action Plan (CAP) – FY 2023 Single Audit Finding 1: Material Adjustments to Recognize Balances in Accordance with U.S. GAAP Planned Corrective Action / Views of Responsible Officials: Management acknowledges the need for a formalized process to ensure that all general ledger balances are reviewed and accurate prior to audit. A third-party accounting firm has been engaged to conduct quarterly reviews and reconciliations of the general ledger to ensure proper documentation and recognition in accordance with U.S. GAAP. Management plans to develop and implement a structured internal review process before submitting the General Ledger balance for audit to ensure alignment with U.S. GAAP. We recognize that this may continue as a finding in the FY 2024 audit; however, the corrective action is in place as of this Single Audit in July 2025. Expected Completion Date: In progress with full implementation as of October 2025 or expected prior to commencement of FY 2025 Single Audit. Responsible Official: Amee Ivie, MSW Chief Executive Officer Finding 2: Completeness of SEFA and Data Collection Form Filing Timeliness Planned Corrective Action / Views of Responsible Officials: We recognize the deficiencies in our prior SEFA submission process. As of July 2025, the organization has engaged a third-party accounting firm to conduct quarterly reconciliations of federal grant activity and maintain a rolling SEFA throughout the fiscal year. Management turnover has stabilized, and processes are now in place to maintain an up-to-date general ledger with accuracy to support a complete and timely SEFA. A documented checklist and timeline have been implemented to ensure timely and accurate reporting. Expected Completion Date: In progress, with full implementation expected prior to commencement of FY 2025 Single Audit. Responsible Official: Amee Ivie, MSW Chief Executive Officer Finding 3: Employee Loan Documentation Planned Corrective Action / Views of Responsible Officials: New leadership has implemented a strict no-loan policy. Any loan or advance to staff must now receive prior written approval from the Executive Board. A formal Employee Loan and Advance Policy is being adopted to ensure any future considerations are properly documented, authorized, and compliant with internal controls. Payment-processing staff will be trained to enforce the new policy and ensure all reimbursements and advances meet approval requirements. Expected Completion Date: September 30, 2025 or expected prior to commencement of FY 2025 Single Audit. Responsible Official: Amee Ivie, MSW Chief Executive Officer Finding 4: Internal Controls Over Compliance – Timesheet Approval and Allowable Costs Planned Corrective Action / Views of Responsible Officials: As of April 2024, the organization implemented a new electronic timekeeping system (SwipeClock) in partnership with a third-party payroll provider. This system includes: • Supervisor approval of all time entries. • A final review by a member of the executive team (CEO, Operations Manager, or Accounting Coordinator). This three-tiered approval process ensures accuracy and accountability in payroll allocation to federal grants. Expected Completion Date: Fully implemented as of April 2024 Responsible Official: Amee Ivie, MSW Chief Executive Officer, AmeeI@cssnv.org

Categories

Allowable Costs / Cost Principles

Other Findings in this Audit

  • 573260 2023-004
    Significant Deficiency
  • 573261 2023-004
    Significant Deficiency
  • 573262 2023-004
    Significant Deficiency
  • 573263 2023-004
    Significant Deficiency
  • 573264 2023-004
    Significant Deficiency
  • 573265 2023-004
    Significant Deficiency
  • 573266 2023-004
    Significant Deficiency
  • 1149701 2023-004
    Significant Deficiency
  • 1149702 2023-004
    Significant Deficiency
  • 1149703 2023-004
    Significant Deficiency
  • 1149704 2023-004
    Significant Deficiency
  • 1149705 2023-004
    Significant Deficiency
  • 1149706 2023-004
    Significant Deficiency
  • 1149707 2023-004
    Significant Deficiency
  • 1149708 2023-004
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
16.575 Crime Victim Assistance $370,181
93.958 Block Grants for Community Mental Health Services $260,413
93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance $187,515
93.391 Activities to Support State, Tribal, Local and Territorial (stlt) Health Department Response to Public Health Or Healthcare Crises $145,484
93.959 Block Grants for Prevention and Treatment of Substance Abuse $131,013
16.017 Sexual Assault Services Formula Program $70,000
93.665 Emergency Grants to Address Mental and Substance Use Disorders During Covid-19 $52,146
93.747 Elder Abuse Prevention Interventions Program $34,529