Finding 573813 (2022-004)

Material Weakness Repeat Finding
Requirement
ABCHI
Questioned Costs
$1
Year
2022
Accepted
2025-08-19
Audit: 364481
Organization: Community Health Service, Inc. (MN)

AI Summary

  • Core Issue: The Organization failed to provide adequate documentation for payroll expenditures and federal grant drawdowns, leading to material noncompliance.
  • Impacted Requirements: This affects compliance with federal regulations on internal controls and documentation as outlined in Title 2 U.S. Code of Federal Regulations Part 200.
  • Recommended Follow-up: Implement procedures to ensure all supporting documentation is maintained for drawdown requests to prevent future issues.

Finding Text

U.S. Department of Health and Human Services Health Center Program Cluster- Health Center Program, Assistance Listing No. 93.224 Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs, Cash Management, Period of Performance, and Procurement, Suspension and Debarment Type of Finding - Material Noncompliance and Material Weakness in Internal Control over Compliance (Repeat Finding) Condition – The Organization was unable to provide adequate supporting documentation for certain payroll expenditures and drawdowns of federal reimbursement grants. Criteria - Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires that a non Federal entity must establish and maintain internal controls to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Cause – Due to inadequate controls over document retainage and the changing of third-party payroll providers, the Organization did not have internal controls in place to ensure proper documentation was maintained to support internal controls over the payroll disbursement process involving federal grant funds and for certain drawdowns of these funds. Effect – Material noncompliance with document retainage and support existed and expenditures for reimbursed costs could have potentially been unallowable. Questioned Costs – $73,415 (unsupported) Context/Sampling – In a non-statistical sample of 60 out of a population of more than 250, the Organization was not able to provide adequate supporting documentation for all selections to ensure controls were in place over their payroll disbursement process. Additionally, in the testing of all 51 drawdowns, 12 of the selections tested lacked adequate documentation to support the eligible payroll or non-payroll related expenditures. Recommendation - We recommend the Organization implement procedures to ensure its supporting documentation is maintained for all drawdown requests submitted. Management Response to Findings – Management concurs with the finding.

Corrective Action Plan

1. Enhance Document Retention Procedures: *We will update our document retention policy to clearly define retention periods for payroll-related records, ensuring compliance with legal and regulatory requirements. This will include retaining all necessary documentation such as payroll reports, tax filings, and third-party payroll contracts. *A secure, organized system will be implemented for storing payroll-related documents, whether physical or digital. This will include utilizing secure cloud storage or an enterprise document management system with restricted access controls. *We will conduct a quarterly review to ensure that documents are being retained for the appropriate time frame and securely disposed of when no longer required. 2. Implement Stronger Controls During Payroll Provider Transitions: *We will formalize and document the process for changing third-party payroll providers. This process will include detailed steps for due diligence, transition planning, data transfer procedures, and ensuring continuous payroll processing during the transition period. *A project team will be assigned for every payroll provider change to ensure proper planning, including backup and contingency plans, data verification, and communication with both internal and external stakeholders. *A comprehensive review of the transition will be conducted after each change, including a reconciliation of payroll records to ensure that all data is accurately transferred, and all systems are functioning properly. 3. Vendor Oversight and Service Level Agreements (SLAs): *We will ensure that future contracts with third-party payroll providers include clear Service Level Agreements (SLAs) outlining the provider's responsibilities in terms of document retention, data security, and transition procedures. This will ensure that providers maintain the necessary standards and practices for managing payroll-related documents.

Categories

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles Cash Management

Other Findings in this Audit

  • 573814 2022-005
    Significant Deficiency Repeat
  • 573815 2022-004
    Material Weakness Repeat
  • 573816 2022-005
    Significant Deficiency Repeat
  • 573817 2022-004
    Material Weakness Repeat
  • 573818 2022-005
    Significant Deficiency Repeat
  • 573819 2022-004
    Material Weakness Repeat
  • 573820 2022-005
    Significant Deficiency Repeat
  • 573821 2022-004
    Material Weakness Repeat
  • 573822 2022-005
    Significant Deficiency Repeat
  • 1150255 2022-004
    Material Weakness Repeat
  • 1150256 2022-005
    Significant Deficiency Repeat
  • 1150257 2022-004
    Material Weakness Repeat
  • 1150258 2022-005
    Significant Deficiency Repeat
  • 1150259 2022-004
    Material Weakness Repeat
  • 1150260 2022-005
    Significant Deficiency Repeat
  • 1150261 2022-004
    Material Weakness Repeat
  • 1150262 2022-005
    Significant Deficiency Repeat
  • 1150263 2022-004
    Material Weakness Repeat
  • 1150264 2022-005
    Significant Deficiency Repeat

Programs in Audit

ALN Program Name Expenditures
93.498 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $217,108
93.224 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $1,636