Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 30, 2026. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by September 30, 2026 (42 days from today).
What is a management decision? →Finding 2024-003 U.S. Department of Housing and Urban Development (HUD) Assistance Listing Number 14.218 – CDBG - Entitlement Grants Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Payroll) Repeat Finding: No Criteria: In accordance with 2 CFR §200.303, The non-federal entity must: (a) Establish and maintain effective internal controls 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 In accordance with 2 CFR 200.430: (i) Standards for Documentation of Personnel Expenses (1) Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (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) Reasonably reflect the total activity for which the employee is compensated by the non-federal entity, not exceeding 100% of compensated activities; (iv) Encompass both federally assisted and all other activities compensated by the non-federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-federal entity’s written policy; (v) Comply with the established accounting policies and practices of the non-federal entity; and (vi) Support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one federal award; a federal award and non-federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. Condition and Context: For the 3 out of 3 employees selected for testing, the timesheet does not support the allocation of work performed to be funded by the federal program. Cause: Timesheets do not report hours by program, so payroll expenses are not allocated to the federal programs based off actual time spent on the grant program. Effect or Potential Effect: Failure to allocate employee pay in accordance with federal requirements could result in a loss of funding. Unallowed costs could be charged to the grant. Questioned Costs: Unknown. Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report
Finding reference: 2024-003 - 14.218 – CDBG - Entitlement Grants Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Action taken: The City has moved to personnel activity reports (PARS) for timesheet reporting to ensure the allocation of the number of hours performed on each program is accurate. The only exception is when an employee works 100% on one grant. Then all working hours are recorded to the grant.
Finding 2024-004 U.S. Department of Health and Human Services Assistance Listing Number 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Cash Management Repeat Finding: No Criteria: In accordance with 2 CFR 200.302: Financial management. (a) Each recipient must expend and account for the federal award in accordance with state laws and procedures for expending and accounting for the recipient’s own funds. In addition, the state’s and the other non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; and the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the federal statutes, regulations, and the terms and conditions of the federal award. Condition and Context: For 1 out of 1 selection, we were unable to agree the drawdown amount to the general ledger to ensure funds were being expended prior to requesting reimbursement. Cause: Controls surrounding the cash drawdown process are not operating effectively. Management could not reconcile information presented in the expenditure report to the underlying records. Effect or Potential Effect: Expenditures are not reviewed prior to submission of request. Expenditures reported to the federal government could be inaccurate. Questioned Costs: $37,527.16. Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed and approved before requests have been submitted. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding reference: 2024-004 - 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Cash Management Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed and approved before requests have been submitted. Action taken: With the hiring of our grant accountant, the policy is that all drawdowns are to be reconciled to general ledger prior to submitting.
Finding 2024-005 U.S. Department of Health and Human Services Assistance Listing Number 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Reporting – Financial Report Repeat Finding: Yes, 2023-010 Criteria: Quarterly SF-425 Federal Financial Reports must be submitted to the HHS Payment Management System 30 days after the end of each quarter of the federal fiscal year. Condition and Context: We reviewed the SF-425 submitted for the period of July 1, 2021 through February 29, 2024 and noted the report was originally submitted on June 18, 2024. Quarterly reports as required were not submitted. Cause: Proper monitoring of grant report submissions was not performed. Effect or Potential Effect: Failure to comply with reporting requirements can result in deferral or restrictions of future funding decisions by the funding agency. Questioned Costs: None. Recommendation: Program management and the Finance Department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding reference: 2024-005- 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Reporting – Financial Report Recommendation: Program management and the Finance Department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Action taken: In addition to hiring a grant manager, the City has purchased OpenGov grant software to ensure compliance, monitoring and the insurance of timely submissions in accordance with the grant
2023-010
Finding 2024-006 U.S. Department of Health and Human Services Assistance Listing Number 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Repeat Finding: No Criteria: Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282), as amended by Section 6202 of Pub. L. No. 110-252, hereafter referred as the “Transparency Act” that are codified in 2 CFR Part 170, recipients (i.e., direct recipients) of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Condition and Context: The City is a direct recipient of Community Programs to Improve Minority Health Grant Program funds from the Department of Health and Human Services and provided first-tier subawards greater than $30,000. The City did not provide support showing submission of their FFATA reporting. Cause: Management does not have procedures in place to ensure subrecipients meeting the reporting requirement are entered into the FSRS portal. Effect or Potential Effect: The City did not report its first-tier subawards in accordance with the Transparency Act requirements. Transactions Tested Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements None None N/A N/A N/A Dollar Amount of Tested Transactions Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements $761,358 $761,358 N/A N/A N/A Questioned Costs: None. Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding reference: 2024-006 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Action taken: In addition to hiring a grant manager to oversee compliance, the City has purchased OpenGov grant software to ensure compliance, monitoring and the insurance of timely submissions in accordance with the grant. This system is designed to send notifications of reporting requirements prior to the due date.
Finding 2024-007 U.S. Department of Health and Human Services Assistance Listing Number 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes, 2023-007, 2023-008, 2023-009 Criteria: A pass-through entity (PTE) must clearly identify to the subrecipient the award as a subaward at the time of subaward (or subsequent subaward modification) by providing the information described in 2 CFR section 200.331(a)(1); all requirements imposed by the PTE on the subrecipient so that the federal award is used in accordance with federal statutes, regulations, and the terms and conditions of the award (2 CFR section 200.331(a)(2)); and any additional requirements that the PTE imposes on the subrecipient in order for the PTE to meet its own responsibility for the federal award (e.g., financial, performance, and special reports) (2 CFR section 200.331(a)(3)). A PTE must also evaluate each subrecipient’s risk of noncompliance for purposes of determining the appropriate subrecipient monitoring related to the subaward (2 CFR section 200.332(b)),and monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals (2 CFR sections 200.332(d) through (f)). Condition and Context: For 1 out of 1 selection, the City was not able to provide support showing evidence of the risk assessment performed prior to granting funds to the subrecipient and of the monitoring of the subrecipient during the year. Additionally, various information related to the funding source and the grant were missing on the memorandum of understanding (assistance listing number, federal department grantor, single audit requirements, etc.) Cause: The program has had significant employee turnover and there was a lack of documentation of these policies and procedures. Program management does not have knowledge of the process used to select subrecipients. Monitoring procedures performed were not documented and reports submitted by the subrecipients were not reviewed. Effect or Potential Effect: Failure to explicitly state federally-imposed requirements and regulations may result in noncompliance by the subrecipient. Selecting subrecipients without a formal evaluation process and performing minimal monitoring procedures increases the risk of noncompliance for the City and could lead to a loss of funding if the subrecipients are deemed noncompliant. Questioned Costs: Unknown. Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Uniform Guidance, as noted in Section 200.331(a). Additionally, program management should develop standardized procedures for selecting and granting subawards. These procedures should be formalized and maintained for future reference. Brief minutes of progress meetings should be taken to show that monitoring is taking place. All reporting by the subrecipient should be reviewed by management of the program. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding reference: 2024-007 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Subrecipient Monitoring Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Uniform Guidance, as noted in Section 200.331(a). Additionally, program management should develop standardized procedures for selecting and granting subawards. These procedures should be formalized and maintained for future reference. Brief minutes of progress meetings should be taken to show that monitoring is taking place. All reporting by the subrecipient should be reviewed by management of the program. Action taken: The HHS Department will outline the selection process within the Notice of Funding Availability. Furthermore, a monitoring schedule will be created and program staff are required to review all reports submitted by the subrecipient.
2023-007, 2023-008, 2023-009
Finding 2024-008 U.S. Department of Health and Human Services Assistance Listing Number 93.224, 93.527 – Health Center Program Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Payroll) Repeat Finding: No Criteria: In accordance with 2 CFR §200.303, The non-federal entity must: (a) 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 In accordance with 2 CFR 200.430: (i) Standards for Documentation of Personnel Expenses (1) Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (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) Reasonably reflect the total activity for which the employee is compensated by the non-federal entity, not exceeding 100% of compensated activities; (iv) Encompass both federally assisted and all other activities compensated by the non-federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-federal entity’s written policy; (v) Comply with the established accounting policies and practices of the non-federal entity; and (vi) Support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. Condition and Context: For the 4 out of 4 employees selected for testing, the timesheet does not support the allocation of work performed to be funded by the federal program. Cause: Timesheets does not report hours by program, so payroll expenses are not allocated to the federal programs based off actual time spent on the grant program. Effect or Potential Effect: Failure to allocate employee pay in accordance with federal requirements could result in a loss of funding. Unallowed costs could be charged to the grant. Section III - Federal Award Findings and Questioned Costs (continued) Finding 2024-008 (continued) Questioned Costs: Unknown. Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding reference: 2024-008 - 93.224, 93.527 – Health Center Program Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Action taken: The City has moved to personnel activity reports (PARS) for timesheet reporting to ensure the allocation of the number of hours performed on each program is accurate. The only exception is an employee that works 100% on one grant. Total working hours are recorded to the grant for this individual.
Finding 2024-009 U.S. Department of Health and Human Services Assistance Listing Number 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Cash Management Repeat Finding: No Criteria: In accordance with 2 CFR 200.302: Financial management, each recipient must expend and account for the federal award in accordance with state laws and procedures for expending and accounting for the recipient’s own funds. In addition, the state’s and the other non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; and the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the federal statutes, regulations, and the terms and conditions of the federal award. Condition and Context: For 1 out of 3 selections, we were unable to agree the drawdown amount to the general ledger to ensure funds were expended prior to requesting reimbursement. Additionally, for 1 out of 3 selections, there was a misapplied payment and incorrect drawdown was requested. Cause: Controls surrounding the cash drawdown process are not operating effectively. Expenditures are not reviewed prior to submission of request. Management could not reconcile information presented in the expenditure report to the underlying records. Effect or Potential Effect: Expenditures reported to the federal government could be inaccurate. Questioned Costs: Unknown. Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed and approved before requests have been submitted. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding reference: 2024-009 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Cash Management Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed and approved before requests have been submitted. Action taken: With the hiring of our grant accountant, the policy is that all drawdowns are to be reconciled to general ledger prior to submitting.
Finding 2024-010 U.S. Department of Health and Human Services Assistance Listing Number 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Repeat Finding: Yes, 2023-005 Criteria: According to 42 USC 254b(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g), and 42 CFR sections 56.303(e), (f), and (g)), health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition and Context: The City did not provide the support showing compliance for 25 out of 25 patients selected. Cause: There is no management oversight in this area. Also, employees have not been properly trained and are not consistently utilizing the Allscripts software that maintains patient data. Effect or Potential Effect: The City is not compliant with federal regulations which could result in the federal government imposing additional requirements or withholding, disallowing or suspending grant funds. Questioned Costs: Unknown. Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. Views of Responsible Officials: Management agrees with the finding. Refer to the Corrective Action Plan Section of this report.
Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. Action taken: All elements required for the sliding fee discount are being properly maintained. All employees have been properly trained in software.
2023-005
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 25, 2025. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by March 25, 2026, which was (147 days ago).
What is a management decision? →Federal Agency: Department of Transportation Federal Program: 20.106 Airport Improvement Program, COVID-19 Airports Programs, and Infrastructure Investment and Jobs Act Programs Identification Number: 3-24-0017-049-2021 Requirement: Reporting Type of Finding: Significant deficiency in internal control over major program Criteria: Federal revenue, federal expenditures and the recipient share are to be reported for the period Form SF-425 is being filed. Condition: Forms SF-425, Federal Financial Report (FFR), were completed using amounts from a varying reporting period. Cause: There was no management oversight of the preparation of Form SF-425. Effect: The Department of Transportation will not have accurate information to assess the status of each project. Context: FFR for Grant 49 was filed with period-end date September 30, 2022 noting $1,488,124 of expenditures when actual expenditures were $1,802,530. The difference was due to a request which was marked as paid on June 30, 2022 and was included in the June 30, 2022 FFR. The request was payable as of June 30, 2022 and was paid in July 2022. Repeat Finding: This finding was reported for the year ended June 30, 2022 as 2022-002 as a significant deficiency in internal control. For the years ended June 30, 2021 and 2020 the finding was reported as 2021-002 and 2020-004, respectively, as a material weakness and noncompliance. Recommendation: The finance department should provide accounting records to the airport that are for the reporting period the Form SF-425 is being prepared. Also, since reports are filed on the cash basis of accounting, any accruals should be reversed so reporting is consistent from period to period. This will provide the Department of Transportation with an accurate accounting of where the project stands. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The finance department will review Form SF-425 compared to financial reports prior to submittals. Quarterly reminders have been initiated to ensure timely reporting moving forward.
2022-002
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Numbers: H80CS29007 H8DCS36329 H8ECS38904 H8FCS41132-01-00 Requirement: Reporting Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Supporting documentation should match the amounts reported on all reports required to be filed for federal programs. Condition: Supporting documentation for key line items on the Uniform Data System (UDS) report and Federal Financial Report (FFR) did not match the reported amounts. Cause: Review and approval of grant reporting did not take place at the level needed to support accurate federal reporting. Also, the Health Center experienced a high volume of employee turnover. Effect: Misinformation presented to the federal government may lead to federal inquiries of those charged with governance. Context: The supporting documentation for the reports selected for testing (six FFRs and one UDS report) did not tie into the amounts reported on the FFRs and UDS. The information used to prepare the reports could not be recreated by Health Center staff. For two key line items in the UDS, Health Center staff could not provide supporting information to support the amounts reported. Amounts in the general ledger did not support the financial data for the varying reporting periods utilized in preparation of the reports. Repeat Finding: This finding was reported for the year ended June 30, 2022 as 2022-003. Recommendation: The Health Center should maintain any and all support utilized in the preparation of federal reports. We also recommend that Health Center staff receive proper training on the patient data software so that they are able to run reports that are necessary for the UDS reports. Documentation of the methods utilized to extract activity from the general ledger for financial reporting should also be maintained. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The Department has instituted a policy to maintain electronic back-ups of all documentation utilized in the submission of both the UDS and FFR. The electronic copies are backed up on a SharePoint service. Additionally, the Finance Staff will review the FFR prior to submission. Furthermore, the Health Center has recently adopted a new EHR with UDS functionality built into the system allowing us to streamline submission.
2022-003
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Numbers: H80CS29007 H8DCS36329 H8ECS38904 H8FCS41132-01-00 Requirement: Special Tests and Provisions Type of Finding: Significant deficiency in internal control over major program; Noncompliance Criteria: Patient charges are adjusted based on income and family size by applying the Health Center’s sliding fee discount schedule. Condition: Sliding fee discounts are not applied appropriately for all patients. Cause: There is no management oversight in this area. Also, employees have not been properly trained and are not consistently utilizing the software that maintains patient data. Effect: The Health Center is not compliant with federal regulations which could result in the federal government imposing additional requirements or withholding, disallowing or suspending grant funds. Context: Out of the 60 patients selected for testing, 11 were charged less than they should have been, 4 patients were charged more than they should have been and 1 patient was unable to be tested due to a lack of documentation. The Health Center’s sliding fee policy calculates fees based on gross monthly pay. For 2 patients selected for testing, the calculation was based on their monthly net pay. Repeat Finding: This finding was reported for the years ended June 30, 2022 and 2021 as 2022-004 and 2021-006, respectively. Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts, including documentation of zero household income. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. The sliding fee discount noted in the patient data software should correspond to the co-pay amount listed on patient billings. Health Center staff in charge of billing should review the patient data to ensure the correct adjustment was made and patients were charged the correct co-pay amount. Any discrepancies should be brought to the attention of Health Center management before bills are processed. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Client intakes are now being updated within the fiscal year, ensuring that client information is accurate and timely. Additionally, the Department's new EHR will prompt providers to update proof of income on an annual basis.
2022-004
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Numbers: H80CS29007 H8DCS36329 H8ECS38904 H8FCS41132-01-00 Requirement: Reporting Type of Finding: Significant deficiency in internal control over major program Criteria: Annual and final FFRs should be submitted 90 days after the report period quarter-end date. The annual UDS should be submitted by February 15th. Condition: Annual and final FFRs and the UDS report filed for reporting periods for the year ended June 30, 2023 were not submitted timely. Cause: Proper monitoring of grant report submissions was not performed. Effect: Failure to comply with reporting requirements can result in deferral or restrictions of future funding decisions by the funding agency. Context: Of the four annual and final FFRs tested, all reports were submitted between 6 and 12 business days late. The annual UDS tested was submitted 7 business days late. Repeat Finding: This finding was reported for the year ended June 30, 2022 as 2022-005. Recommendation: The Health Center and Finance Department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The Department has instituted a policy that FFRs must be submitted within 30 days of the end of the quarter. This will allow for any unforeseen circumstances that may delay submission.
2022-005
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Subrecipient Monitoring Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: A pass-through entity’s subrecipient monitoring policies and procedures should provide information about the entity’s process to identify subawards, evaluate risk of noncompliance and perform monitoring procedures based upon identified risks. Condition: Program management does not have knowledge of the process used to select subrecipients. Monitoring procedures performed were not documented and reports submitted by the subrecipients were not reviewed. Cause: The program has had significant employee turnover and there was a lack of documentation of these policies and procedures. Effect: Selecting subrecipients without a formal evaluation process and performing minimal monitoring procedures increases the risk of noncompliance for the City and could lead to a loss of funding if the subrecipients are deemed noncompliant. Context: The City has two subrecipients to which they pass on the federal funding. There was no knowledge or documentation as to how the subrecipients were chosen or how the subaward agreements were developed. The City did hold progress meetings with subrecipients, but there were no minutes taken or any documentation maintained related to these meetings. Financial reports submitted by the subrecipients to program management were not reviewed to ensure grant funds were utilized for allowable activities and costs. Repeat Finding: This finding was reported for the year ended June 30, 2022 as 2022-007. Recommendation: Program management should develop standardized procedures for selecting and granting subawards. These procedures should be formalized and maintained for future reference. Brief minutes of progress meetings should be taken to show that monitoring is taking place. All reporting by the subrecipient should be reviewed by management of the program. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The Department will outline the selection process within the Notice of Funding Availability. Furthermore, a monitoring schedule will be created, and program staff are required to review all reports submitted by the subrecipient.
2022-007
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Subrecipient Monitoring Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Subaward agreements should include terms and conditions of the subaward, making the subrecipient aware of the award information required by Uniform Guidance Section 200.331(a) sufficient for the pass-through entity to comply with federal statutes, regulations and the terms and conditions of the award. Condition: Subaward agreements do not make Uniform Guidance requirements and regulations clear. They also do not contain language that supports subrecipient classification. Cause: Program management does not possess adequate knowledge of subrecipient monitoring requirements and did not prepare an adequate subrecipient agreement. Effect: Failure to explicitly state federally-imposed requirements and regulations may result in noncompliance by the subrecipient and lead to federal inquiries of those charged with governance. Context: Subrecipient agreements are titled “Memorandums of Understanding” instead of subaward agreements. The agreement with the one subrecipient does not state a dollar amount that is being passed-through over the course of the agreement. The terms and conditions do not explicitly mention the Uniform Guidance. The agreement makes references to both subcontractors and subrecipients, and never explicitly identifies the subrecipient as such. The other subrecipient agreement refers to the City of Frederick, Maryland as “the Sponsor”, not a pass-through entity and does not explicitly name the subrecipient as such. The agreement does not mention the Uniform Guidance. Repeat Finding: This finding was reported for the year ended June 30, 2022 as 2022-008. Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Uniform Guidance, as noted in Section 200.331(a). Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
All subaward grant agreements are now required to contain a provision outlining all federal conditions of the funds, including relevant regulations with 2 CFR Part 200, otherwise known as Uniform Guidance.
2022-008
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Subrecipient Monitoring Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: A pass-through entity must verify that subrecipients expected to be audited as required by 2 CFR Part 200, Subpart F, met this requirement. This verification ensures that the subrecipients take timely and appropriate action on deficiencies identified through single audits. Condition: Program management did not perform this verification. Cause: Program management does not possess adequate knowledge of subrecipient monitoring requirements. Effect: Failure to verify the single audit status of subrecipients may lead to unresolved subrecipient noncompliance and lead to federal inquiries of those charged with governance. Context: Program management stated that the subrecipients did not undergo single audits. The Federal Audit Clearinghouse website noted that both subrecipients had filed single audits for the subaward period which included program 93.137. Repeat Finding: This finding was reported for the year ended June 30, 2022 as 2022-009. Recommendation: Program management should obtain the single audits performed for the subrecipients and review for program deficiencies. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The Department will include language in all grant agreements notifying subrecipients that entities with federal funds in excess of $750,000 are subject to Single Audit requirements. Subrecipients will also be required to provide copies of their most recent Single Audit as a condition of award and will be verified in the Federal Audit Clearinghouse.
2022-009
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Reporting Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Supporting documentation must be maintained for all reports required to be filed for federal programs. Amounts reported on financial reports should be supported by the accounting records that support the audited financial statements and the schedule of expenditures of federal awards. Reports should be filed by the due date required in the grant agreement. Condition: Supporting documentation for key line items on the quarterly progress reports was not maintained. Amounts reported as cash receipts and cash disbursements did not match the underlying support. Brown Plus could not verify the submittal dates of reports. Cause: Review and approval of grant reporting did not take place at the level needed to support accurate federal reporting. Also, the Minority Health Program experienced a high volume of employee turnover. Effect: Misinformation presented to the federal government may lead to federal inquiries of those charged with governance. Context: The reports selected for testing (two quarterly financial and performance progress reports) did not have documentation maintained that supported the program data stated in the reports. As noted in the directions for the quarterly FFR, cash receipts and cash disbursements are only actual cash received. Brown Plus could not trace the cash disbursements and cash receipts to the general ledger detail. Out of the two quarterly financial reports tested, one was submitted a day late. The two performance reports tested did not include submittal dates. Staff at the Minority Health Center were unable to locate documentation of the submittal dates for the quarterly progress reports, which prevented us from verifying whether the reports were submitted on time. Repeat Finding: This finding was reported for the year ended June 30, 2022 as 2022-010. Recommendation: Program management should maintain any and all support utilized in the preparation of federal reports. Documentation of the methods utilized to extract activity from the general ledger for financial reporting should also be maintained. Minority Health Program staff preparing reports should carefully review reporting instructions to ensure the correct amounts are reported and that reports are submitted timely. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The Department has instituted a policy to maintain electronic back-ups of all documentation utilized to submit all federal reports. The electronic copies are backed up on a SharePoint service. Additionally, the Finance Staff will review the FFR prior to submission.
2022-010
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Activities Allowed or Unallowed; Allowable Costs and Cost Principles Type of Finding: Significant deficiency in internal control over major program Criteria: Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one federal award; a federal award and non-federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases or an unallowable activity and a direct or indirect cost activity. Condition: An employee of the program did not have any pay allocated to the program in the general ledger. Cause: The City believes an override occurred in the accounting system excluding the employee from the program. There is no support for this conclusion. Effect: Failure to allocate employee pay in accordance with federal requirements could result in a loss of funding. Also, payroll amounts charged to another program may be overstated. Context: For all five pay periods tested, an employee whom was allocated to the Minority Health Program in the payroll system was excluded from the Minority Health Program in the accounting software. Support could not be provided showing that this allocation was appropriate. Recommendation: The Minority Health Program staff should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The City has developed a Personnel Activity Report (PAR) that has each federal grant program available as a drop-down menu item. Employees will be required to indicate time spent on grant activities daily. This PAR will be reviewed an approved by the employees' supervisor and then submitted to Payroll for allocation to appropriate grant funds. The PAR will be retained by Payroll as backup.
Federal Agency: Department of Health and Human Services Federal Program: 93.568 Low-Income Home Energy Assistance Pass-Through Entity: Maryland Department of Human Services Identification Number: FIA/OHEP/22-001 Requirement: Cash Management Type of Finding: Significant deficiency in internal control over major program Criteria: Interest earned in excess of $500 on federal cash draws should be remitted annually to the Department of Health and Human Services, Payment Management System (Uniform Guidance Section 200.305(9)). Condition: The amount of interest on federal cash draws could not be determined. Cause: Management does not have any support for the interest earned specific to federal cash draws for this program. Effect: If interest in excess of $500 was earned, the City would owe the Department of Health and Human Services. Context: During inquiries with program management and the finance department, it was noted that the City does not believe they have earned interest in excess of $500. The City had total draw downs for the program of $2,393,735 which are subject to earning interest. The City was ultimately not able to provide any evidence to support the fact that the draw downs did not earn less than $500 and, as such, their claim could not be corroborated. Repeat Finding: This finding was reported for the year ended June 30, 2022 as 2022-013. Recommendation: The City should track interest earned on each applicable federal program to ensure they are in compliance with federal regulations. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The City is no longer receiving advance funds. Therefore, no interest is being earned.
2022-013
Federal Agency: Department of Health and Human Services Federal Program: 93.568 Low-Income Home Energy Assistance Pass-Through Entity: Maryland Department of Human Services Identification Number: FIA/OHEP/22-001 Requirement: Reporting Type of Finding: Significant deficiency in internal control over major program Criteria: Financial reports should be submitted to the awarding agency by the 15th of the subsequent month. Condition: Financial reports filed for reporting periods within the year ended June 30, 2023 were not submitted timely. Cause: Review and approval of grant reporting did not take place at the level needed to support accurate federal reporting. Also, the Low-Income Home Energy Assistance program experienced a high volume of employee turnover. Effect: Failure to comply with reporting requirements can result in deferral or restrictions of future funding decisions by the funding agency. Context: Of the four financial reports tested, three reports were submitted between 1 and 39 business days late. Repeat Finding: This finding was reported for the year ended June 30, 2022 as 2022-014. Recommendation: Low-Income Home Energy Assistance program management and the finance department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
SharePoint is being utilized to track reporting requirements to ensure timely filings. The Department will continue to explore ways to streamline the process. However, final numbers for the prior month are typically not available until the second week after the close of the month. This is complicated by the need for controls in place to ensure the final numbers are correct.
2022-014
Federal Agency: Department of Health and Human Services Federal Program: 93.568 Low-Income Home Energy Assistance Pass-Through Entity: Maryland Department of Human Services Identification Number: FIA/OHEP/22-001 Requirement: Eligibility Type of Finding: Significant deficiency in internal control over major program Criteria: Client benefit amounts are calculated based on household size, level of income and heating type. Weatherization benefit amounts are paid out based on income and eligibility of the building. Condition: Benefit amounts paid directly to landlords on behalf of clients were unable to be recalculated. Weatherization crisis status was unable to be verified based on client documentation. Cause: Management did not implement and enforce procedures to ensure documentation was maintained for landlord direct payments and crisis status of heating and cooling equipment. Effect: Failure to comply with reporting requirements can result in deferral or restrictions of future funding decisions by the funding agency. Context: Of the 25 Maryland Energy Assistance Program (MEAP) client files tested, 2 involved payments made directly to landlords. For these cases, we were unable to recalculate or verify the benefit amounts. Discussions with program management indicated that documentation supporting these payments is not retained, as the benefit amounts are automatically calculated by the State's system. Additionally, of the 5 Weatherization Assistance Program (WAP) client files tested, 4 were designated as crisis clients. However, their profiles lacked documentation to support their crisis status. Program staff indicated that the Hancock software does not require supporting documentation for crisis status, and as a result, some energy auditors include a narrative summary of the crisis condition, while others omit it entirely. Recommendation: Program management should obtain a thorough understanding of the calculation methodology used by the State’s software for payments made directly to landlords and implement procedures to independently verify or recalculate benefit amounts, where feasible, to identify any potential errors. Additionally, program management should establish standardized procedures for documenting crisis status in client profiles to ensure consistent and sufficient support for eligibility determination. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The Maryland Departments of Human Services (DHS) and Housing and Community Development (DHCD) are the direct recipient of the federal funds for OHEP and WAP, respectively. Because of this, all verification occurs on the state level and HHS does not have access to all pertinent information. As the recipient of these funds, HHS is informed by DHS or DHCD when a Crisis Client is to be served by HHS. HHS is not responsible for the verification of Crisis Client eligibility for either program.
Federal Agency: Department of Health and Human Services Federal Program: 93.568 Low-Income Home Energy Assistance Pass-Through Entity: Maryland Department of Human Services Identification Number: FIA/OHEP/22-001 Requirement: Period of Performance Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: In accordance with the terms and conditions of the grant agreement, administrative costs charged to the grant must relate to allowable activities incurred during the grant period of July 1, 2021 through June 30, 2023. Condition: Administrative costs were charged to the grant outside the grant period. Cause: Management has not established or implemented sufficient internal controls to ensure that expenditures charged to the grant are limited to those incurred within the allowable grant period. Effect: Inclusion of costs outside the allowable grant period in reports to the federal government may lead to federal inquiries of those charged with governance. Known Questioned Costs: Known questioned costs related to our identified error total $43,878. Context: Common area maintenance (CAM) fees related to the rent of the program building for the period August 2017 through June 2021 were charged to the grant during the year ended June 30, 2023. Recommendation: Before using federal grant funds to pay for expenditures, program staff should ensure that costs are within the period of performance of the grant. We recommend notifying the pass-through entity of this error and returning the funds received for ineligible expenses. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
All expenditures will be verified prior to disbursement to ensure they are paid within the defined grant period.
Federal Agency: Department of the Treasury Federal Program: 21.027 Coronavirus State and Local Fiscal Recovery Funds Identification Number: SLT-8854 Requirement: Reporting Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Amounts reported on financial reports should be supported by the accounting records that support the audited financial statements and the schedule of expenditures of federal awards. Condition: Amounts reported as obligations and expenditures on the Project and Expenditure Reports did not match the supporting documentation. Cause: Review and approval of grant reporting did not take place at the level needed to support accurate federal reporting. Also, the program has had significant employee turnover. Effect: Misinformation presented to the federal government may lead to federal inquiries of those charged with governance. Context: The supporting documentation for one out of the two Project and Expenditure Reports did not tie to the amounts reported on the report. The information used to prepare the reports did not take into consideration accruals or judgments made by the finance department for the use of federal funds. Recommendation: We recommend that management implement a standardized reconciliation process to ensure that all Project and Expenditure Reports align with supporting documentation. This process should involve coordination between the reporting team and finance to validate that all amounts reported accurately reflect the use of federal funds. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
A standardized reconciliation process has been recated by our grant accountant to ensure all project and expenditure reports are aligned.
Federal Agency: Department of Housing and Urban Development Federal Program: 14.231 Emergency Solutions Grant Program Pass-Through Entity: Maryland Department of Housing and Community Development Identification Number: E-20-DW-24-0001 Requirement: Activities Allowed or Unallowed Type of Finding: Significant deficiency in internal control over major program Criteria: Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one federal award; a federal award and non-federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases or an unallowable activity and a direct or indirect cost activity. Condition: Support for payroll costs claimed under the program was not maintained for all pay periods. Cause: Supporting documentation is not maintained for payroll allocations. Effect: Failure to allocate employee pay in accordance with federal requirements could result in a loss of funding. Context: Out of five pay periods tested, two pay periods excluded an allocation of a program employee’s time. For the remaining three pay periods, the aforementioned program employee was allocated to the program but no documentation was maintained supporting the allocation. Recommendation: The Emergency Solutions program staff should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The City has developed a Personnel Activity Report (PAR) that has each federal grant program available as a drop-down menu item. Employees will be required to indicate time spent on grant activities daily. This PAR will be reviewed an approved by the employees' supervisor and then submitted to Payroll for allocation to appropriate grant funds. The PAR will be retained by Payroll as backup.
Federal Agency: Department of Housing and Urban Development Federal Program: 14.231 Emergency Solutions Grant Program Pass-Through Entity: Maryland Department of Housing and Community Development Identification Number: E-20-DW-24-0001 Requirement: Special Tests and Provisions Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: The grant recipient must pay each subrecipient for allowable costs within 30 days after receiving the subrecipient’s complete payment request. Condition: Payments were not made to subrecipients within 30 days of the request date. Cause: Program management does not possess adequate knowledge or monitoring procedures to ensure timely processing and payment of subrecipient invoices. Effect: Failure to make timely payments to subrecipients in accordance with federal requirements could result in a loss of funding. Context: Of the 32 subrecipient payments reviewed, 13 were not made within the required 30-day period. The delays ranged from a minimum of 5 business days to a maximum of 84 days. Recommendation: The Emergency Solutions program staff should carefully monitor subrecipient request dates and communicate regularly with the finance department to ensure timely payment of the requests. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The Department will continue to explore ways to streamline the process. Furthermore, the Department is no longer responsible for ESG pass-through funds.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 25, 2024. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by September 25, 2024, which was (693 days ago).
What is a management decision? →Federal Agency: Department of Transportation Federal Program: 20.106 Airport Improvement Program Identification Number: 3-24-0017-049-2021 Requirement: Reporting Type of Finding: Significant deficiency in internal control over major program Criteria: Federal revenue, federal expenditures and the recipient share are to be reported for the period Form SF-425 is being filed. Condition: Forms SF-425, Federal Financial Report (FFR), were completed using amounts from a varying reporting period and excluded expenditures that were incurred during the reporting period. Cause: There was no management oversight of the preparation of Form SF-425. Effect: The Department of Transportation will not have accurate information to assess the status of each project. Context: FFR for Grant 49 was filed with period-end date September 30, 2021 noting zero expenditures when actual expenditures were $5,500. Repeat Finding: This finding was reported for the years ended June 30, 2021 and 2020 as 2021-002 and 2020-004, respectively, as a material weakness and noncompliance. The issue was not as severe for the year ended June 30, 2022. Recommendation: The finance department should provide accounting records to the airport that are for the reporting period the Form SF-425 is being prepared. This will provide the Department of Transportation with an accurate accounting of where the project stands. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
A financial grant accountant has been assigned to work directly with the Airport to assist in providing accounting records for the Form-SF-425.
2021-002
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Numbers: H80CS29007 H8DCS36329 H8ECS38904 H8FCS41132-01-00 Requirement: Reporting Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Supporting documentation should match the amounts reported on all reports required to be filed for federal programs. Condition: Supporting documentation for key line items on the Uniform Data System (UDS) report and Federal Financial Report (FFR) did not match the reported amounts. Cause: Review and approval of grant reporting did not take place at the level needed to support accurate federal reporting. Also, the Health Center experienced a high volume of employee turnover. Effect: Misinformation presented to the federal government may lead to federal inquiries of those charged with governance. Context: The supporting documentation for the reports selected for testing (five FFRs and one UDS report) did not tie into the amounts reported on the FFRs and UDS. Also, the information could not be recreated by current staff at the Health Center. Amounts in the general ledger did not support the financial data for the varying reporting periods utilized in preparation of the reports. Recommendation: The Health Center should maintain any and all support utilized in the preparation of federal reports. We also recommend that Health Center staff receive proper training on the patient data software so that they are able to run reports that are necessary for the UDS reports. Documentation of the methods utilized to extract activity from the general ledger for financial reporting should also be maintained. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The Health Center has put new processes in place to maintain support for federal reports. The Allscripts subscription coding has been improved so reports align with reporting needs.
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Numbers: H80CS29007 H8DCS36329 H8ECS38904 H8FCS41132-01-00 Requirement: Special Tests and Provisions Type of Finding: Significant deficiency in internal control over major program; Noncompliance Criteria: Patient charges are adjusted based on income and family size by applying the Health Center’s sliding fee discount schedule. Condition: Sliding fee discounts are not applied appropriately for all patients. Cause: There is no management oversight in this area. Also, employees have not been properly trained and are not consistently utilizing the Allscripts software that maintains patient data. Effect: The Health Center is not compliant with federal regulations which could result in the federal government imposing additional requirements or withholding, disallowing or suspending grant funds. Context: Out of the 60 patients selected for testing, 12 were charged less than they should have been, 5 patients were charged more than they should have been and 4 patients were unable to be tested due to a lack of documentation. Repeat Finding: This finding was reported for the year ended June 30, 2021 as 2021-006. Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts, including documentation of zero household income. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. The sliding fee discount noted in Allscripts should correspond to the co-pay amount listed on patient billings. Health Center staff in charge of billing should review the patient data to ensure the correct adjustment was made and patients were charged the correct co-pay amount. Any discrepancies should be brought to the attention of Health Center management before bills are processed. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Outreach staff are now updating all patient intakes once per calendar year or upon site visit to ensure information is up to date. Responsibilities have been modified with employees assigned specifically to focus on operations, compliance and consistency.
2021-006
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Numbers: H80CS29007 H8DCS36329 H8ECS38904 H8FCS41132-01-00 Requirement: Reporting Type of Finding: Significant deficiency in internal control over major program Criteria: Annual and final FFRs should be submitted 90 days after the report period quarter-end date. Condition: Annual FFRs filed for reporting periods within the year ended June 30, 2022 were not submitted timely. Cause: Proper monitoring of grant report submissions was not performed. Effect: Failure to comply with reporting requirements can result in deferral or restrictions of future funding decisions by the funding agency. Context: Of the four annual FFRs tested, three reports were submitted between 16 and 19 business days late. Repeat Finding: This finding was reported for the year ended June 30, 2021 as 2021-005. Recommendation: The Health Center and Finance Department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Grant database has been developed to tract grants and reporting due dates. Finance and the Health Center are meeting regularly to ensure timely submittal.
2021-005
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Number: H80CS29007 Requirement: Activities Allowed or Unallowed Type of Finding: Significant deficiency in internal control over major program Criteria: Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one federal award; a federal award and non-federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases or an unallowable activity and a direct or indirect cost activity. Condition: An employee was charged to the federal program without the allocation of pay being supported. Cause: Timesheets are not broken down by program, so payroll expenses are not allocated based off actual time spent on the grant program. Effect: Failure to allocate employee pay in accordance with federal requirements could result in a loss of funding. Context: For four out of eight pay periods tested, an employee’s pay was allocated 50% to the Health Center Program. Support could not be provided showing that this allocation was appropriate. Recommendation: The Health Center should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Staff allocations are reviewed regularly to ensure they are based on work assignments. We are now tracking changes to allocations for historical reference.
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Subrecipient Monitoring Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: A pass-through entity’s subrecipient monitoring policies and procedures should provide information about the entity’s process to identify subawards, evaluate risk of noncompliance and perform monitoring procedures based upon identified risks. Condition: Program management does not have knowledge of the process used to select subrecipients. Monitoring procedures performed were not documented and reports submitted by the subrecipients were not reviewed. Cause: The program has had significant employee turnover and there was a lack of documentation of these policies and procedures. Effect: Selecting subrecipients without a formal evaluation process and performing minimal monitoring procedures increases the risk of noncompliance for the City and could lead to a loss of funding if the subrecipients are deemed noncompliant. Context: The City selected two subrecipients to pass federal funding onto. There was no knowledge or documentation as to how the subrecipients were chosen or how the subaward agreements were developed. The City did hold progress meetings with subrecipients, but there were no minutes taken or any documentation maintained related to these meetings. Financial reports submitted by the subrecipients to program management were not reviewed to ensure grant funds were utilized for allowable activities and costs. Recommendation: Program management should develop standardized procedures for selecting and granting subawards. These procedures should be formalized and maintained for future reference. Brief minutes of progress meetings should be taken to show that monitoring is taking place. All reporting by the subrecipient should be reviewed by management of the program. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Ensure all employees are trained on the City of Frederick procurement process and other contractual obligations. New Senior Assistant Director has been assigned to ensure compliance in this area.
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Subrecipient Monitoring Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Subaward agreements should include terms and conditions of the subaward, making the subrecipient aware of the award information required by Uniform Guidance Section 200.331(a) sufficient for the pass-through entity to comply with federal statutes, regulations and the terms and conditions of the award. Condition: Subaward agreements do not make Uniform Guidance requirements and regulations clear. They also do not contain language that supports subrecipient classification. Cause: Program management does not possess adequate knowledge of subrecipient monitoring requirements. Effect: Failure to explicitly state federally-imposed requirements and regulations may result in noncompliance by the subrecipient and lead to federal inquiries of those charged with governance. Context: Subrecipient agreements are titled “Memorandums of Understanding” instead of subaward agreements. The agreement with the one subrecipient does not state a dollar amount that is being passed-through over the course of the agreement. The terms and conditions do not explicitly mention the Uniform Guidance. The agreement makes references to both subcontractors and subrecipients, and never explicitly identifies the subrecipient as such. The other subrecipient agreement refers to the City of Frederick, Maryland as “the Sponsor”, not a pass-through entity and does not explicitly name the subrecipient as such. The agreement does not mention the Uniform Guidance. Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Uniform Guidance, as noted in Section 200.331(a). Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
To ensure compliance, agreement and contractual documents will be reviewed or drafted by the City's legal office.
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Subrecipient Monitoring Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: A pass-through entity must verify that subrecipients expected to be audited as required by 2 CFR Part 200, Subpart F, met this requirement. This verification ensures that the subrecipients take timely and appropriate action on deficiencies identified through single audits. Condition: Program management did not perform this verification. Cause: Program management does not possess adequate knowledge of subrecipient monitoring requirements. Effect: Failure to verify the single audit status of subrecipients may lead to unresolved subrecipient noncompliance and lead to federal inquiries of those charged with governance. Context: Program management stated that the subrecipients did not undergo single audits. The Federal Audit Clearinghouse website noted that both subrecipients had filed single audits for the subaward period which included program 93.137. Recommendation: Program management should obtain the single audits performed for the subrecipients and review for program deficiencies. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Housing and Human Services have established regular meeting to review each grant. Additionally, our Grants Manager is now engaged in all areas to compliance and consistency.
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Reporting Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Supporting documentation must be maintained for all reports required to be filed for federal programs. Amounts reported on financial reports should be supported by the accounting records that support the audited financial statements and the schedule of expenditures of federal awards. Condition: Supporting documentation for key line items on the quarterly progress reports and monthly reports required to be filed in the first six months of the project was not maintained. Amounts reported as cash receipts did not match the underlying support and cash disbursements included accrued amounts. Cause: Review and approval of grant reporting did not take place at the level needed to support accurate federal reporting. Also, the minority health program experienced a high volume of employee turnover. Effect: Misinformation presented to the federal government may lead to federal inquiries of those charged with governance. Context: The reports selected for testing (two quarterly financial and performance progress reports and three monthly special reports) did not have documentation maintained that supported the program data stated in the reports. As noted in the directions for the quarterly FFR, cash receipts and cash disbursements are only actual cash received. The amounts reported by the City included expenditures which were in accounts payable and Brown Plus could not trace the cash receipts to the general ledger detail. Recommendation: Program management should maintain any and all support utilized in the preparation of federal reports. Documentation of the methods utilized to extract activity from the general ledger for financial reporting should also be maintained. Minority health staff preparing reports should carefully review reporting instructions to ensure the correct amounts are reported. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
A grants database has been developed for tracking and storing grant related information. Finance has assigned a grants manager to ensure the accuracy of financial reporting.
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Reporting Type of Finding: Significant deficiency in internal control over major program Criteria: Quarterly FFRs must be submitted to the award agency 30 days after the report period quarter-end date. Condition: Quarterly FFRs filed for reporting periods within the year ended June 30, 2022 were not submitted timely. Cause: Proper monitoring of grant report submissions was not performed. Effect: Failure to comply with reporting requirements can result in deferral or restrictions of future funding decisions by the funding agency. Context: The two quarterly FFRs tested were submitted between one and six business days late. Recommendation: Program management and the Finance Department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
A grants database has been developed to track grant deadlines. Regular meetings are scheduled to monitor grant status and ensure compliance.
Federal Agency: Department of Health and Human Services Federal Program: 93.137 Community Programs to Improve Minority Health Grant Program Identification Number: 1 CPIMP211296-01-00 Requirement: Reporting Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Any obligation to a subrecipient over $25,000 is required to be reported under the Federal Funding Accountability and Transparency Act (FFATA) requirements. Condition: First tier subawards were not entered into the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) portal during the audit period. One subrecipient agreement does not include a subaward amount. Cause: Management does not have procedures in place to ensure subrecipients meeting the reporting requirement are entered into the FSRS portal. Effect: First tier subrecipients are not reported in the FSRS portal, causing noncompliance with the FFATA. Misinformation presented to the federal government may lead to federal inquiries of those charged with governance. Context: There were two subrecipient agreements that met the requirements of a first tier subaward during the audit period. These subawards were not reported in the FSRS portal during the year under audit. A summarization of transactions tested, as well as questioned costs, are below. Recommendation: Program management should make the first-tier subaward determination when funds are awarded to recipients and promptly enter qualifying subawards into the FSRS portal. We recommend that one individual is responsible for entering the subaward into the portal and another individual is responsible for checking the portal before the deadline (one month after the subaward is made). Adding this additional review of the portal would ensure that qualifying subawards are appropriately reported. Subaward agreements should include the amount of funding. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Whe subrecipients are identified we will assign staff to update portal, monitor and control work, finances, and reporting.
Federal Agency: Department of Health and Human Services Federal Program: 93.568 Low-Income Home Energy Assistance Identification Number: FIA/OHEP/22-001 Requirement: Cash Management Type of Finding: Significant deficiency in internal control over major program Criteria: Interest earned in excess of $500 on federal cash draws should be remitted annually to the Department of Health and Human Services, Payment Management System (Uniform Guidance Section 200.305(9)). Condition: The amount of interest on federal cash draws could not be determined. Cause: Management does not have any support for the interest earned specific to federal cash draws for this program. Effect: If interest in excess of $500 was earned, the City would owe the Department of Health and Human Services. Context: During inquiries with program management and the finance department, it was noted that the City does not believe they have earned interest in excess of $500. The City had total draw downs for the program of $2,053,514 which are subject to earning interest. The City was ultimately not able to provide any evidence to support the fact that the draw downs did not earn less than $500 and, as such, their claim could not be corroborated. Recommendation: The City should track interest earned on each applicable federal program to ensure they are in compliance with federal regulations. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Most funds are a pass through or on a reimbursement basis, therefore interest has always been de minimus. The City will re-evaluate.
Federal Agency: Department of Health and Human Services Federal Program: 93.568 Low-Income Home Energy Assistance Identification Number: FIA/OHEP/22-001 Requirement: Reporting Type of Finding: Significant deficiency in internal control over major program Criteria: Financial reports should be submitted to the awarding agency by the 15th of the subsequent month. Condition: Financial reports filed for reporting periods within the year ended June 30, 2022 were not submitted timely. Cause: Review and approval of grant reporting did not take place at the level needed to support accurate federal reporting. Also, the Low-Income Home Energy Assistance program experienced a high volume of employee turnover. Effect: Failure to comply with reporting requirements can result in deferral or restrictions of future funding decisions by the funding agency. Context: Of the four financial reports tested, three reports were submitted between 41 and 84 business days late. Recommendation: Low-Income Home Energy Assistance program management and the finance department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
A database has been established to monitor reporting and due dates to ensure compliance.
Federal Agency: Small Business Administration Federal Program: 59.075 Shuttered Venue Operators Grant Program Identification Number: SBAHQ21SV012046.2 Requirement: Allowable Costs and Cost Principles Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Costs claimed under a federal award program cannot be claimed under another federal program in any reporting period. Condition: Program expenditures included costs that were claimed under another federal program in the prior fiscal year. Cause: Management has not implemented adequate controls over the allowability of expenditures. Effect: Inclusion of costs already claimed under another federal program may lead to federal inquiries of those charged with governance and could cause the federal agency to request a refund for those costs. Known Questioned Costs: Our identified error of expenses claimed under another federal program was $55,867. Context: $55,867 of costs claimed under the federal program were also claimed under the Coronavirus Relief Fund during the year ended June 30, 2021. Recommendation: Before using federal grant funds to pay for expenditures, the Program management should ensure that these costs were not claimed under a separate grant. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
New financial grant accountant has been assigned to work with departments to ensure proper accounting of expenditures.
Federal Agency: U.S. Small Business Administration Federal Program: 59.075 Shuttered Venue Operators Grant Program Identification Number: SBAHQ21SV012046.2 Requirement: Period of Performance Type of Finding: Significant deficiency in internal control over major program Criteria: The period to incur costs was 3/1/2020 and 6/30/2022. The U.S. Small Business Administration’s Shuttered Venue Operators Grant webinar on Auditing and the Compliance Supplement notes that a cost is incurred when the obligation for payment has been made. Condition: Program expenditures included costs that were incurred outside the period of performance. Cause: Management does not have an adequate understanding of federal program requirements. Effect: Inclusion of costs outside the period of performance may lead to federal inquiries of those charged with governance and could cause the federal agency to request a refund for those costs. Context: Four transactions tested included advertising and janitorial services which were performed in February 2020. The obligation for payment was made when the services were performed. Recommendation: Program management should review program definitions and attend federal agency webinars to ensure complete and accurate understanding of program standards. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Weinberg staff assigned to grant will review program definitions and attend webinars to ensure complete understanding and compliance.
Federal Agency: U.S. Small Business Administration Federal Program: 59.075 Shuttered Venue Operators Grant Program Identification Number: SBAHQ21SV012046.2 Requirement: Activities Allowed or Unallowed Type of Finding: Significant deficiency in internal control over major program Criteria: Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one federal award; a federal award and non-federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using difference allocation bases or an unallowable activity and a direct or indirect cost activity. Condition: Support for payroll costs claimed under the program was not maintained for all pay periods. Cause: Management did not maintain the electronic support for each pay period. Effect: Failure to maintain support for costs claimed may result in inquiries by the federal entity to those charged with governance. Context: During the height of the COVID-19 pandemic, the Box Office Manager would email the Executive Theater Manager the employees’ weekly hours worked in lieu of a physical timesheet. Out of five pay periods tested, one pay period did not have email correspondence to support the employees’ time. Recommendation: Email correspondence used in the approval process of any costs should be maintained in the same manner as physical invoices or timesheets. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Moving forward, email correspondence used in the approval process shall be maintained by Weinberg Center management in the same manner as physical invoices or timesheets.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 30, 2022. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by September 30, 2022, which was (1419 days ago).
What is a management decision? →Federal Agency: Department of Transportation Federal Program: 20.106 Airport Improvement Program Identification Number: 3-24-0017-043-2017 3-24-0017-045-2018 3-24-0017-046-2019 3-24-0017-047-2020 Requirement: Reporting Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Federal revenue, federal expenditures and the recipient share are to be reported for the period Form SF-425 is being filed. Condition: Forms SF-425, Federal Financial Report, were completed using amounts from a varying reporting period and excluded expenditures that were incurred during the reporting period. Cause: There was no management oversight of the preparation of Forms SF-425. Effect: The Department of Transportation will not have accurate information to assess the status of each project. Context: Reports for the above noted Grants 43-46 were filed with period end dates of September 30, 2020, but the balances reported were as of varying dates including June 30, 2019; July 31, 2020 and August 31, 2020. Also, Grant 47 was filed with a period end date of September 30, 2020 noting zero expenditures when actual expenditures were $2,800. Repeat Finding: This finding was reported for the year ended June 30, 2020 as 2020-004. Recommendation: The Finance Department should provide accounting records to the airport that are for the reporting period the Form SF-425 is being prepared. This will provide the Department of Transportation with an accurate accounting of where the project stands. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Finding reference: 2021-002 ? 20.106 Airport Improvement Program ? Material weakness; Noncompliance Action taken: The City now provides quarterly financial information relating to open airport improvement program grants to airport personnel and have communicated to them the need to use the proper period information when filing reports. Forms SF-425 are to be reviewed by finance personnel prior to submission to the FAA. The Director of Finance is the contact person who is responsible for the corrective action. This corrective action will begin immediately.
2020-004
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Number: H80CS29007 Requirement: Allowable Costs and Cost Principles Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Per 2 CFR 200, Subpart E 200.431(f), the portion of automobile costs furnished by the non-federal entity that relates to personal use by employees (including transportation to and from work) is unallowable as a fringe benefit or indirect (F&A) costs regardless of whether the cost is reported as taxable income to the employees. Condition: Program expenditures included costs that are unallowable under the federal program. Cause: Management has not implemented adequate controls over the allowability of expenditures. Effect: Inclusion of unallowable costs in reports to the federal government may lead to federal inquiries of those charged with governance. Likely Questioned Costs: By extrapolating our identified error over the population of non-payroll expenditures claimed under this federal program during the year ended June 30, 2021, we estimate that $48,284 of costs were unallowable. Context: Program expenditures claimed under Grant H80CS29007 included the payment of an employee?s parking space. Recommendation: Before using federal grant funds to pay for expenditures, the Health Center staff should ensure that costs meet allowability requirements by using the guidance outlined in the OMB Compliance Supplement, as well as the Code of Federal Regulations cost principles. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan
Finding reference: 2021-003 ? 93.224 Health Center Program - Material weakness ? Noncompliance Action taken: HHS Senior Assistant Director will review all criteria funding and document all restricted funding per grant. By doing so, any unencumbered funds will be approved by object code. This action will ensure both Division Director and HHS finance will not inappropriately use funds, deeming it unallowable funds. The HHS Senior Assistant Director is the contact person who is responsible for the corrective action. This corrective action will begin implementation immediately.
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Number: H80CS29007 H8ECS38904 H8CCS34380 H8DCS36329 Requirement: Reporting Type of Finding: Material weakness in internal control over major program; Noncompliance Criteria: Supporting documentation must be maintained for all reports required to be filed for federal programs. Condition: Supporting documentation for key line items on the Uniform Data System (UDS) report and Federal Financial Report (FFR) was not maintained. Also, carryover grant funds were not differentiated from current period grant funds in the general ledger. Cause: Review and approval of grant reporting did not take place at the level needed to support accurate federal reporting. Also, the Health Center experienced a high volume of employee turnover. Health Center staff noted that carryover funds are not assigned their own project code in the general ledger making it impossible to differentiate carryover cash receipts, disbursements or expenditures from those of the current period grant. Effect: Misinformation presented to the federal government may lead to federal inquiries of those charged with governance. Context: The reports selected for testing (four FFRs and one UDS report) did not have documentation maintained that supported the financial and program data stated in the reports. Also, the information could not be recreated by current staff at the Health Center. Amounts in the general ledger did not support the financial data for the varying reporting periods utilized in preparation of the reports. Recommendation: The Health Center should maintain any and all support utilized in the preparation of federal reports. We also recommend that Health Center staff receive proper training on the patient data software so that they are able to run reports that are necessary for the UDS reports. Documentation of the methods utilized to extract activity from the general ledger for financial reporting should also be maintained. Carryover funds approved by the grantor should have their own project code in the general ledger to separately track those funds to ensure accurate figures are reported to the federal government. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Finding reference: 2021 ? 004 ? 93.224 Health Center Program - Material weakness - Noncompliance Action Taken: Health Center staff, including Medical Director, Data Administrator, Accounting Assistant, and Senior Assistant Director have contacted Health Center Data Allscripts who sent out their representative. Changes were made to the reporting methods to be more accurate; and training will be provided to the health center staff to increase the accuracy of reporting. The Senior Assistant Director and the Accounting Assistant will be working with the City Finance Office to ensure all carryover and new grants have a project number which will be associated with the new fiscal year ensuring no duplicates are carried over. The HHS Senior Assistant Director is the contact person who is responsible for the corrective action. This corrective action will begin implementation immediately.
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Number: H80CS29007 H8ECS38904 H8CCS34380 H8DCS36329 Requirement: Reporting Type of Finding: Significant deficiency in internal control over major program Criteria: Quarterly FFRs should be submitted 30 days after the report period end date. Annual and final FFRs should be submitted 90 days after the report period quarter end date. The UDS for 2020 was due on February 15, 2021. Condition: FFRs and the UDS report filed for reporting periods within the year ended June 30, 2021were not submitted timely. Cause: Proper monitoring of grant report submissions was not performed. Effect: Failure to comply with reporting requirements can result in deferral or restrictions of future funding decisions by the funding agency. Context: Of the four FFRs tested, one was submitted timely. The other three repots were submitted between 1 and 80 business days late. The UDS was submitted on March 3, 2022. Recommendation: The Health Center and Finance Department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Finding reference: 2021 ? 005 ? 93.224 Health Center Program - Significant deficiency in internal control over major program Action Taken: The Assistant Director of Human Services, and the Grants manager (yet to be hired) will put in place a grants schedule to align with the finance team to ensure FFRs are submitted timely. The HHS Senior Assistant Director is the contact person who is responsible for the corrective action. This corrective action will begin implementation immediately.
Federal Agency: Department of Health and Human Services Federal Program: 93.224 Health Center Program Identification Number: H80CS29007 H8ECS38904 H8CCS34380 H8DCS36329 Requirement: Special Tests and Provisions Type of Finding: Significant deficiency in internal control over major program; Noncompliance Criteria: Patient charges are adjusted based on income and family size by applying the Health Center?s sliding fee discount schedule. Condition: Sliding fee discounts are not applied appropriately for all patients. Cause: There is no management oversight in this area. Also, employees have not been properly trained and are not consistently utilizing the Allscripts software that maintains patient data. Effect: The Health Center is not compliant with federal regulations which could result in the federal government imposing additional requirements or withholding, disallowing or suspending grant funds. Context: Out of the 40 patients selected for testing, 11 were charged less than they should have been, 1 patient was charged more than they should have been and 2 patients were unable to be tested due to a lack of documentation. Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts, including documentation of zero household income. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. The sliding fee discount noted in Allscripts should correspond to the co-pay amount listed on patient billings. Health Center staff in charge of billing should review the patient data to ensure the correct adjustment was made and patients were charged the correct co-pay amount. Any discrepancies should be brought to the attention of Health Center management before bills are processed. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
Finding reference: 2021 ? 006 ? Health Center Program ? Significant deficiency in internal control over major program; Noncompliance Action Taken: HHS went through a Mock OSV June 29-30, 2021, which findings included Chapter 9 (Finance) discrepancy including sliding fee. The City has been working to rectify these issues from FY 2021 and the sliding fee is being assessed and already steps have been taken to rectify discrepancies in both the clinic and reporting models in Allscripts. The HHS Senior Assistant Director is the contact person who is responsible for the corrective action. This corrective action will begin implementation immediately.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 29, 2021. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by September 29, 2021, which was (1785 days ago).
What is a management decision? →Federal Agency: Department of Transportation Federal Program:20.106 Airport Improvement Program Identification Number:3-24-0017-043-2017 3-24-0017-044-2018 3-24-0017-045-2018 Requirement: Reporting Type of Finding: Material weakness in internal control over major program; Noncompliance Condition: Forms SF-425, Federal Financial Report, were completed using amounts from a varying reporting period and included non-federal expenditures. Criteria: Federal revenue, federal expenditures, and the recipient share are to be reported for the period form SF-425 is being filed. Non-federal revenue and expenditures are not to be included on the report. Cause: There was no management oversight of the preparation of Form SF-425. Effect: The Department of Transportation will not have accurate information to assess the status of each project. Context: Reports for the above noted grants were filed with period end dates of September 30, 2019 but the balances reported were as of June 30, 2019. Also, award 3-24-0017-045-2018 included non-federal expenditures which effected the cash on hand and recipient share calculations to be incorrect. Recommendation: The finance department should provide accounting records to the airport that are for the reporting period the SF-425 is being prepared. This will provide the Department of Transportation with an accurate accounting of where the project stands. Views of Responsible Official(s) and Planned Corrective Actions: See corrective action plan.
The department of finance will provide quarterly reports to airport management regarding activity for the airport improvement program grants. The Director of Finance is the contact person who is responsible for the corrective action. This corrective action plan will begin immediately.
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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