EIN: 836000113
UEI: C6A8LHPE9YA5
Audit also covers 3 related EINs: 830287956, 831065210, 861065210 · unlinked EINs have no separate FAC filing
Audited by: Porter, Muirhead, Cornia, & Howard
Oversight agency: 21 [Department of the Treasury]
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Data as of August 28, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on February 5, 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 August 5, 2026 (25 days ago).
What is a management decision? →Significant Deficiency in Internal Control over Compliance 2025-003 Procurement, Suspension and Debarment Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Assistance Listing No: 21.027 Federal Agency: U.S. Department of Treasury Federal Award Identification: ARPA-1087 Grant Year: 2023 Applicable Pass-through Entity: Wyoming Office of State Lands and Investments Criteria Uniform Guidance requires non-federal entities to perform procurement procedures that provide for full and open competition and comply with applicable federal, state, and local laws and regulations. In addition, 2 CFR §180 and §200.213 require non-federal entities to ensure that vendors receiving federal funds are not suspended or debarred, and to have procedures in place to verify vendor eligibility prior to contract award. Condition Non-federal entities should follow procurement procedures and retain documentation to verify that vendors were not suspended or debarred prior to entering into a covered transaction for contracts or making payments using federal funds. Cause The County lacks documentation to verify that vendors were not suspended or debarred prior to entering into a covered transaction for contracts or making payments using federal funds. Effect or Potential Effect Without formal documentation of procurement policies followed regarding suspension and debarment, the County is at increased risk of noncompliance with federal regulations. This increases the likelihood of potential contracting with ineligible vendors. Continued noncompliance could result in audit findings, required repayment of federal funds, or other sanctions from grantor agencies. Questioned Costs None identified. Context Of three covered transactions tested, the County did not have formal documentation for two covered transactions showing they were not with vendors considered suspended or debarred. This formal documentation can take the form of certification from the vendor, a clause included in the contract, or formal SAM search performed and retained in the procurement documents. Identification as a Repeat Finding This is not a repeat finding Recommendation We recommend that management adhere to written procurement policies and procedures in accordance with Uniform Guidance requirements. These policies include procedures to verify and document vendor suspension and debarment status prior to contract award and periodically thereafter, such as through SAM.gov verification. Views of Responsible Officials Management agrees with the finding and plans to adhere to compliance with suspension and debarment policies including documentation requirements. Implementation is expected to occur during the next fiscal year. See Corrective Action Plan
Show full finding ▾Hide full finding ▴Significant Deficiency in Internal Control over Compliance 2025-003 Procurement, Suspension and Debarment Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Assistance Listing No: 21.027 Federal Agency: U.S. Department of Treasury Federal Award Identification: ARPA-1087 Grant Year: 2023 Applicable Pass-through Entity: Wyoming Office of State Lands and Investments Criteria Uniform Guidance requires non-federal entities to perform procurement procedures that provide for full and open competition and comply with applicable federal, state, and local laws and regulations. In addition, 2 CFR §180 and §200.213 require non-federal entities to ensure that vendors receiving federal funds are not suspended or debarred, and to have procedures in place to verify vendor eligibility prior to contract award. Condition Non-federal entities should follow procurement procedures and retain documentation to verify that vendors were not suspended or debarred prior to entering into a covered transaction for contracts or making payments using federal funds. Cause The County lacks documentation to verify that vendors were not suspended or debarred prior to entering into a covered transaction for contracts or making payments using federal funds. Effect or Potential Effect Without formal documentation of procurement policies followed regarding suspension and debarment, the County is at increased risk of noncompliance with federal regulations. This increases the likelihood of potential contracting with ineligible vendors. Continued noncompliance could result in audit findings, required repayment of federal funds, or other sanctions from grantor agencies. Questioned Costs None identified. Context Of three covered transactions tested, the County did not have formal documentation for two covered transactions showing they were not with vendors considered suspended or debarred. This formal documentation can take the form of certification from the vendor, a clause included in the contract, or formal SAM search performed and retained in the procurement documents. Identification as a Repeat Finding This is not a repeat finding Recommendation We recommend that management adhere to written procurement policies and procedures in accordance with Uniform Guidance requirements. These policies include procedures to verify and document vendor suspension and debarment status prior to contract award and periodically thereafter, such as through SAM.gov verification. Views of Responsible Officials Management agrees with the finding and plans to adhere to compliance with suspension and debarment policies including documentation requirements. Implementation is expected to occur during the next fiscal year. See Corrective Action Plan
Name of Contact Person Anna Kinder, Casper Natrona County Department of Health, Executive Director Board of County Commissioners Corrective Action Plan Management agrees with the finding and plans to adhere to compliance with suspension and debarment policies including documentation requirements. Implementation is expected to occur during the next fiscal year. Proposed Completion Date June 30, 2026
FAC accepted this audit on February 20, 2025 — management decision was due August 20, 2025.
Material Weakness in Internal Control over Compliance 2024-004 Activities Allowed or Unallowed and Allowable Costs/Costs Principles Program: Community Services Block Grant (CSBG) & Health Center Program Cluster Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care)(HCH). Federal Assistance Listing No: 93.569 and 93.224 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Grant year: 2023 and 2024 Federal Award Identification: Unknown Applicable Pass-through Entity: Wyoming Department of Health (CSBG), Direct (HCH) Criteria Accounting practices of the non-Federal entity must provide for adequate documentation to support costs charged to the Federal award. Standards for accounting practices in Uniform Guidance 2 CFR part 200.400 state that the accounting practices of the recipient and subrecipient must be consistent with these cost principles and support the accumulation of costs as required by these cost principles, including maintaining adequate documentation to support costs charged to the Federal award. Condition CAP was missing a consistent system of internal control for accumulation of costs charged to the federal program. The detail of costs maintained in the accounting system charged to the grants differed from the amounts included in the reimbursement requests. Cause Due to an accounting system conversion, adjustments were made in the general ledger to the beginning account balances. This resulted in unreconcilable differences from the detail in the accounting system after adjustment to what was originally submitted for reimbursement. Additionally, CAP began utilizing a separate payroll provider that required an integration of the payroll register monthly to the general ledger. Mapping and coding errors existed during the initial integrations of the payroll register to the general ledger resulting in additional differences from the general ledger to the amounts submitted for reimbursement for wage and benefit expense allocated to the grants. Effect or Potential Effect CAP was unable to provide an accurate accumulation of costs for amounts charged to the grant. Questioned Cost 93.224 - $9,274 93.569 - $28,355 Context The comparison of the general ledger for grant costs to the total of the amounts submitted for reimbursement resulted in differences of $9,274 for the Health Center Program Cluster Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) grant, and $28,355 Community Services Block Grant. Identification as a repeat finding This is not a repeat finding Recommendation We recommend CAP review its policies and procedures related to the internal controls over accumulation of expenditures related to grants to ensure the detail agrees to amounts submitted for reimbursement. Views of Responsible Officials Over the past year, CAPNC has continued to make significant improvements to its fiscal practices, particularly in navigating the software conversion from an archaic, unsupported system to Sage Intacct. This new software has modernized and deployed the levels of internal controls that were previously missing due to inadequate fiscal personnel oversight and technical capability. Current staff have been trained under Sage Intacct and Wipfli consultants to properly track accounts payable (A/P), accounts receivable (A/R), payroll, and grant management, ensuring data integrity and compliance. Resulting journal entries are in place to bring system in alignment and current as of July 2024, alleviating any further discrepancies related to past staff and old software. The old system will be archived as required under retention. See Corrective Action Plan
Show full finding ▾Hide full finding ▴Material Weakness in Internal Control over Compliance 2024-004 Activities Allowed or Unallowed and Allowable Costs/Costs Principles Program: Community Services Block Grant (CSBG) & Health Center Program Cluster Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care)(HCH). Federal Assistance Listing No: 93.569 and 93.224 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Grant year: 2023 and 2024 Federal Award Identification: Unknown Applicable Pass-through Entity: Wyoming Department of Health (CSBG), Direct (HCH) Criteria Accounting practices of the non-Federal entity must provide for adequate documentation to support costs charged to the Federal award. Standards for accounting practices in Uniform Guidance 2 CFR part 200.400 state that the accounting practices of the recipient and subrecipient must be consistent with these cost principles and support the accumulation of costs as required by these cost principles, including maintaining adequate documentation to support costs charged to the Federal award. Condition CAP was missing a consistent system of internal control for accumulation of costs charged to the federal program. The detail of costs maintained in the accounting system charged to the grants differed from the amounts included in the reimbursement requests. Cause Due to an accounting system conversion, adjustments were made in the general ledger to the beginning account balances. This resulted in unreconcilable differences from the detail in the accounting system after adjustment to what was originally submitted for reimbursement. Additionally, CAP began utilizing a separate payroll provider that required an integration of the payroll register monthly to the general ledger. Mapping and coding errors existed during the initial integrations of the payroll register to the general ledger resulting in additional differences from the general ledger to the amounts submitted for reimbursement for wage and benefit expense allocated to the grants. Effect or Potential Effect CAP was unable to provide an accurate accumulation of costs for amounts charged to the grant. Questioned Cost 93.224 - $9,274 93.569 - $28,355 Context The comparison of the general ledger for grant costs to the total of the amounts submitted for reimbursement resulted in differences of $9,274 for the Health Center Program Cluster Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) grant, and $28,355 Community Services Block Grant. Identification as a repeat finding This is not a repeat finding Recommendation We recommend CAP review its policies and procedures related to the internal controls over accumulation of expenditures related to grants to ensure the detail agrees to amounts submitted for reimbursement. Views of Responsible Officials Over the past year, CAPNC has continued to make significant improvements to its fiscal practices, particularly in navigating the software conversion from an archaic, unsupported system to Sage Intacct. This new software has modernized and deployed the levels of internal controls that were previously missing due to inadequate fiscal personnel oversight and technical capability. Current staff have been trained under Sage Intacct and Wipfli consultants to properly track accounts payable (A/P), accounts receivable (A/R), payroll, and grant management, ensuring data integrity and compliance. Resulting journal entries are in place to bring system in alignment and current as of July 2024, alleviating any further discrepancies related to past staff and old software. The old system will be archived as required under retention. See Corrective Action Plan
Over the past year, CAPNC has continued to make significant improvements to its fiscal practices, particularly in navigating the software conversion from an archaic, unsupported system to Sage Intacct. This new software has modernized and deployed the levels of internal controls that were previously missing due to inadequate fiscal personnel oversight and technical capability. Current staff have been trained under Sage Intacct and Wipfli consultants to properly track accounts payable (A/P), accounts receivable (A/R), payroll, and grant management, ensuring data integrity and compliance. Resulting journal entries are in place to bring system in alignment and current as of July 2024, alleviating any further discrepancies related to past staff and old software. The old system will be archived as required under retention. To further stabilize and formalize these improvements, a Certified Public Accountant will be added as a consulting CFO. This role supports the ongoing development of fiscal operations. Additionally, it is recognized that the payroll vendor, ADP, was initially slow to address issues with uploaded data when notified by CAPNC, responded officially after CAPNC alerted repeatedly that it had now elevated to an audit issue. This issue has since been remedied. Staff have shown marked improvement over previous legacy staff in documentation, accountability, and monitoring. Payroll services in general are able to provide real-time features and accountability for time, resulting in more accurate, reliable, and allocable time recording. Payroll records are reviewed, and time studies are performed for all staff to ensure the allocation methodology is appropriate, consistent, and aligned with staff performance. Wipfli Consulting is providing technical assistance over an additional contract period to update policies and procedures for the fiscal area, in accordance with Uniform Guidance, and allow for advance reporting, as well as provide CPA support. The curriculum includes comprehensive training for all administrative leadership staff, covering fiscal oversight, grants management, and compliance. Allocations are regularly reviewed by the leadership team to ensure appropriate methodology and consistency with grant expectations and regulations. Board members have access to the accounting software through a Board portal for further oversight, enhancing transparency and accountability. Review of finance in conducted monthly by Board of Director’s Finance Committee.
Significant Deficiency over Internal Control 2024-005 Cash Management Program: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) Federal Assistance Listing No: 93.224 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Grant year: 2022 Federal Award Identification: Unknown Applicable Pass-through Entity: None Criteria When non-federal entities are funded under the reimbursement method, expenditures included in reimbursement requests should have supporting documentation and the entity should have paid for the costs for which the reimbursement is requested prior to the date of the reimbursement request. Condition Community Action Partnership of Natrona County (CAP) submitted reimbursement requests in excess of actual expenditures. Cause Due to turnover in grant management, processes that had previously existed were overlooked. A reconciliation of grant expenditures to the amounts requested for reimbursement was not performed resulting in reimbursements that were greater than the actual grant expenditures Effect or potential effect Without adequate review and reconciliations of reimbursement requests, an entity may submit inaccurate expenditure reimbursement requests. Questioned Cost None Context We tested 20 out of 31 reimbursement requests submitted during the grant period by comparing each reimbursement request to the actual expenditures in the CAP general ledger. Additionally, we reconciled total grant reimbursements to total grant expenditures. We noted that total grant reimbursement requests exceeded the total grant expenditures by $3,222. Identification as a Repeat Finding Repeat finding of 2023-003 Recommendation We recommend CAP review its policies and procedures related to the internal controls over reimbursement requests to assure reimbursement requests have supporting documentation and reconcile to actual expenditures incurred. Views of Responsible Officials Over the past year, CAPNC has continued to make significant improvements to its fiscal practices, particularly in navigating the software conversion from an archaic, unsupported system to Sage Intacct. This new software has modernized and deployed the levels of internal controls that were previously missing due to inadequate fiscal personnel oversight and technical capability. Current staff have been trained under Sage Intacct and Wipfli consultants to properly track accounts payable (A/P), accounts receivable (A/R), payroll, and grant management, ensuring data integrity and compliance. Resulting journal entries are in place to bring system in alignment and current as of July 2024, alleviating any further discrepancies related to past staff and old software. The old system will be archived as required under retention. See Corrective Action Plan
Show full finding ▾Hide full finding ▴Significant Deficiency over Internal Control 2024-005 Cash Management Program: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) Federal Assistance Listing No: 93.224 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Grant year: 2022 Federal Award Identification: Unknown Applicable Pass-through Entity: None Criteria When non-federal entities are funded under the reimbursement method, expenditures included in reimbursement requests should have supporting documentation and the entity should have paid for the costs for which the reimbursement is requested prior to the date of the reimbursement request. Condition Community Action Partnership of Natrona County (CAP) submitted reimbursement requests in excess of actual expenditures. Cause Due to turnover in grant management, processes that had previously existed were overlooked. A reconciliation of grant expenditures to the amounts requested for reimbursement was not performed resulting in reimbursements that were greater than the actual grant expenditures Effect or potential effect Without adequate review and reconciliations of reimbursement requests, an entity may submit inaccurate expenditure reimbursement requests. Questioned Cost None Context We tested 20 out of 31 reimbursement requests submitted during the grant period by comparing each reimbursement request to the actual expenditures in the CAP general ledger. Additionally, we reconciled total grant reimbursements to total grant expenditures. We noted that total grant reimbursement requests exceeded the total grant expenditures by $3,222. Identification as a Repeat Finding Repeat finding of 2023-003 Recommendation We recommend CAP review its policies and procedures related to the internal controls over reimbursement requests to assure reimbursement requests have supporting documentation and reconcile to actual expenditures incurred. Views of Responsible Officials Over the past year, CAPNC has continued to make significant improvements to its fiscal practices, particularly in navigating the software conversion from an archaic, unsupported system to Sage Intacct. This new software has modernized and deployed the levels of internal controls that were previously missing due to inadequate fiscal personnel oversight and technical capability. Current staff have been trained under Sage Intacct and Wipfli consultants to properly track accounts payable (A/P), accounts receivable (A/R), payroll, and grant management, ensuring data integrity and compliance. Resulting journal entries are in place to bring system in alignment and current as of July 2024, alleviating any further discrepancies related to past staff and old software. The old system will be archived as required under retention. See Corrective Action Plan
Over the past year, CAPNC has continued to make significant improvements to its fiscal practices, particularly in navigating the software conversion from an archaic, unsupported system to Sage Intacct. This new software has modernized and deployed the levels of internal controls that were previously missing due to inadequate fiscal personnel oversight and technical capability. Current staff have been trained under Sage Intacct and Wipfli consultants to properly track accounts payable (A/P), accounts receivable (A/R), payroll, and grant management, ensuring data integrity and compliance. Resulting journal entries are in place to bring system in alignment and current as of July 2024, alleviating any further discrepancies related to past staff and old software. The old system will be archived as required under retention. To further stabilize and formalize these improvements, a Certified Public Accountant will be added as a consulting CFO. This role supports the ongoing development of fiscal operations. Additionally, it is recognized that the payroll vendor, ADP, was initially slow to address issues with uploaded data when notified by CAPNC, responded officially after CAPNC alerted repeatedly that it had now elevated to an audit issue. This issue has since been remedied. Staff have shown marked improvement over previous legacy staff in documentation, accountability, and monitoring. Payroll services in general are able to provide real-time features and accountability for time, resulting in more accurate, reliable, and allocable time recording. Payroll records are reviewed, and time studies are performed for all staff to ensure the allocation methodology is appropriate, consistent, and aligned with staff performance. Wipfli Consulting is providing technical assistance over an additional contract period to update policies and procedures for the fiscal area, in accordance with Uniform Guidance, and allow for advance reporting, as well as provide CPA support. The curriculum includes comprehensive training for all administrative leadership staff, covering fiscal oversight, grants management, and compliance. Allocations are regularly reviewed by the leadership team to ensure appropriate methodology and consistency with grant expectations and regulations. Board members have access to the accounting software through a Board portal for further oversight, enhancing transparency and accountability. Review of finance in conducted monthly by Board of Director’s Finance Committee.
2023-003
FAC accepted this audit on February 23, 2024 — management decision was due August 23, 2024.
2023-001 Activities Allowed or Unallowed and Allowable Costs/Costs Principles Program: COVID-19 Emergency Rental Assistance Program Federal Assistance Listing No: 21.023 County Recipient: Community Action Partnership of Natrona County (CAP) Federal Agency: U.S. Department of the Treasury Grant year: 2023 Federal Award Identification: Unknown Applicable Pass-through Entity: Wyoming Department of Family Services Criteria Accounting practices of the non-Federal entity must provide for adequate documentation to support costs charged to the Federal award. Additionally, standards for documentation of personnel expenses in Uniform Guidance 2 CFR part 200.430 Compensation – personal services state that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. Among various other requirements, these records must: • Be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. • Support the distribution of the employee’s salary or wages among specific activities or costs 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. • In accordance with Department of Labor regulations implementing the Fair Labor Standards Act (FLSA) (29 CFR part 516), charges for the salaries and wages of nonexempt employees, in addition to the supporting documentation described in this section, must also be supported by records indicating the total number of hours worked each day. Condition CAP was missing a consistent system of internal control for tracking and approving the salaries and wages and other costs charged to the federal program. There were several timecards and transactions that were not approved by the supervisor or another individual knowledgeable of the grant. Additionally, journal entries were posted to classify salaries and wages to the grant without a supporting allocation and approval. For the transactions that were lacking support it was not possible to verify the costs were allowable. Therefore the amounts associated with these transactions are reported as questioned costs. Cause Due to turnover in grant management, processes that had previously existed were overlooked, which resulted in a lack of consistent approval of costs and an inconsistent system for the allocation of salaries and wages charged to the grant. Additionally, records that reflect the work performed were unavailable. Effect or potential effect CAP was unable to provide supporting documentation that the costs allocated to the grant were allowable. Questioned Cost $17,393 Context The internal control and compliance testing performed included testing 60 transactions out of 270 total grant transactions. Of the items tested, 32% of the transactions were missing approvals or adequate supporting documentation of the time and expense allocated to the grant. Identification as a repeat finding This is not a repeat finding. Recommendation We recommend CAP review its policies and procedures related to the internal controls over payroll and other transactions related to grants. Views of Responsible Officials CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. Payroll services were outsourced to ADP payroll services in order to provide real time features and accountability for time. This allows recording of time more accurate, reliable and allocable. Payroll records are reviewed and time studies are being performed for all staff to ensure allocation methodology, once selected is appropriate, consistent and in alignment with staff performance. Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. See Corrective Action Plan
Show full finding ▾Hide full finding ▴2023-001 Activities Allowed or Unallowed and Allowable Costs/Costs Principles Program: COVID-19 Emergency Rental Assistance Program Federal Assistance Listing No: 21.023 County Recipient: Community Action Partnership of Natrona County (CAP) Federal Agency: U.S. Department of the Treasury Grant year: 2023 Federal Award Identification: Unknown Applicable Pass-through Entity: Wyoming Department of Family Services Criteria Accounting practices of the non-Federal entity must provide for adequate documentation to support costs charged to the Federal award. Additionally, standards for documentation of personnel expenses in Uniform Guidance 2 CFR part 200.430 Compensation – personal services state that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. Among various other requirements, these records must: • Be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. • Support the distribution of the employee’s salary or wages among specific activities or costs 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. • In accordance with Department of Labor regulations implementing the Fair Labor Standards Act (FLSA) (29 CFR part 516), charges for the salaries and wages of nonexempt employees, in addition to the supporting documentation described in this section, must also be supported by records indicating the total number of hours worked each day. Condition CAP was missing a consistent system of internal control for tracking and approving the salaries and wages and other costs charged to the federal program. There were several timecards and transactions that were not approved by the supervisor or another individual knowledgeable of the grant. Additionally, journal entries were posted to classify salaries and wages to the grant without a supporting allocation and approval. For the transactions that were lacking support it was not possible to verify the costs were allowable. Therefore the amounts associated with these transactions are reported as questioned costs. Cause Due to turnover in grant management, processes that had previously existed were overlooked, which resulted in a lack of consistent approval of costs and an inconsistent system for the allocation of salaries and wages charged to the grant. Additionally, records that reflect the work performed were unavailable. Effect or potential effect CAP was unable to provide supporting documentation that the costs allocated to the grant were allowable. Questioned Cost $17,393 Context The internal control and compliance testing performed included testing 60 transactions out of 270 total grant transactions. Of the items tested, 32% of the transactions were missing approvals or adequate supporting documentation of the time and expense allocated to the grant. Identification as a repeat finding This is not a repeat finding. Recommendation We recommend CAP review its policies and procedures related to the internal controls over payroll and other transactions related to grants. Views of Responsible Officials CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. Payroll services were outsourced to ADP payroll services in order to provide real time features and accountability for time. This allows recording of time more accurate, reliable and allocable. Payroll records are reviewed and time studies are being performed for all staff to ensure allocation methodology, once selected is appropriate, consistent and in alignment with staff performance. Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. See Corrective Action Plan
2023-001 Activities Allowed or Unallowed and Allowable Costs/Costs Principles Program Emergency Rental Assistance Program Name of Contact Person Kelly Wessels, Executive Director Corrective Action Plan • CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. • Payroll services were outsourced to ADP payroll services in order to provide real time features and accountability for time. This allows recording of time more accurate, reliable and allocable. Payroll records are reviewed and time studies are being performed for all staff to ensure allocation methodology, once selected is appropriate, consistent and in alignment with staff performance. o Time entry occurs electronically in real time; hourly employees are assigned a schedule, and salaried staff are monitored o Time cards are electronically submitted and approved electronically to ensure time is recorded as it occurs. o Time off records are also submitted for approval electronically and leave is approved based on County personnel guidance. • Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: o Internal controls o Allowable compensation and employee benefits o Cost allocation methods o Governing body financial responsibilities o Budgeting o Financial reporting o Financial management systems o Documentation and record retention o Financial policies and procedures o Allowable costs • All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. Proposed Completion Date June 30, 2024
2023-002 Activities Allowed or Unallowed and Allowable Costs/Costs Principles Program: COVID-19 Community Services Block Grant Federal Assistance Listing No: 93.569 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Grant year: 2022 and 2023 Federal Award Identification: Unknown Applicable Pass-through Entity: Wyoming Department of Health Criteria Accounting practices of the non-Federal entity must provide for adequate documentation to support costs charged to the Federal award. Standards for documentation of personnel expenses in Uniform Guidance 2 CFR part 200.430 Compensation – personal services state that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. Among various other requirements, these records must: • Be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. • Support the distribution of the employee’s salary or wages among specific activities or costs 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. • In accordance with Department of Labor regulations implementing the Fair Labor Standards Act (FLSA) (29 CFR part 516), charges for the salaries and wages of nonexempt employees, in addition to the supporting documentation described in this section, must also be supported by records indicating the total number of hours worked each day. Grant agreements with Wyoming Department of Health include a Statement of Work. The Statement of Work includes a requirement that that the grantee conducts a time allocation analysis for any position dually-funded from other sources of funds to account for apportioned time charged against the contract. Condition CAP was missing a consistent system of internal control for tracking and approving the salaries and wages and other costs charged to the federal program. There were several timecards and transactions that were not approved by the supervisor or another individual knowledgeable of the grant. Additionally, journal entries were posted to classify salaries and wages to the grant without a supporting allocation and approval. For the transactions that were lacking support it was not possible to verify the costs were allowable. Therefore the amounts associated with these transactions are reported as questioned costs. Cause Due to turnover in grant management, processes that had previously existed were overlooked, which resulted in a lack of consistent approval of costs and an inconsistent system for the allocation of salaries and wages charged to the grant. Additionally, records that reflect the work performed were unavailable Effect or potential effect CAP was unable to provide supporting documentation that the costs allocated to the grant were allowable. Questioned Cost $32,364 Context The internal control and compliance testing performed included testing 50 transactions out of 981 total grant transactions. Of the items tested, 18% of the transactions were missing approvals or adequate supporting documentation of the time and expense allocated to the grant. Identification as a repeat finding This is not a repeat finding Recommendation We recommend CAP review its policies and procedures related to the internal controls over payroll, expenditures related to grants. Views of Responsible Officials CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. Payroll services were outsourced to ADP payroll services in order to provide real time features and accountability for time. This allows recording of time more accurate, reliable and allocable. Payroll records are reviewed and time studies are being performed for all staff to ensure allocation methodology, once selected is appropriate, consistent and in alignment with staff performance. Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. See Corrective Action Plan
Show full finding ▾Hide full finding ▴2023-002 Activities Allowed or Unallowed and Allowable Costs/Costs Principles Program: COVID-19 Community Services Block Grant Federal Assistance Listing No: 93.569 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Grant year: 2022 and 2023 Federal Award Identification: Unknown Applicable Pass-through Entity: Wyoming Department of Health Criteria Accounting practices of the non-Federal entity must provide for adequate documentation to support costs charged to the Federal award. Standards for documentation of personnel expenses in Uniform Guidance 2 CFR part 200.430 Compensation – personal services state that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. Among various other requirements, these records must: • Be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. • Support the distribution of the employee’s salary or wages among specific activities or costs 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. • In accordance with Department of Labor regulations implementing the Fair Labor Standards Act (FLSA) (29 CFR part 516), charges for the salaries and wages of nonexempt employees, in addition to the supporting documentation described in this section, must also be supported by records indicating the total number of hours worked each day. Grant agreements with Wyoming Department of Health include a Statement of Work. The Statement of Work includes a requirement that that the grantee conducts a time allocation analysis for any position dually-funded from other sources of funds to account for apportioned time charged against the contract. Condition CAP was missing a consistent system of internal control for tracking and approving the salaries and wages and other costs charged to the federal program. There were several timecards and transactions that were not approved by the supervisor or another individual knowledgeable of the grant. Additionally, journal entries were posted to classify salaries and wages to the grant without a supporting allocation and approval. For the transactions that were lacking support it was not possible to verify the costs were allowable. Therefore the amounts associated with these transactions are reported as questioned costs. Cause Due to turnover in grant management, processes that had previously existed were overlooked, which resulted in a lack of consistent approval of costs and an inconsistent system for the allocation of salaries and wages charged to the grant. Additionally, records that reflect the work performed were unavailable Effect or potential effect CAP was unable to provide supporting documentation that the costs allocated to the grant were allowable. Questioned Cost $32,364 Context The internal control and compliance testing performed included testing 50 transactions out of 981 total grant transactions. Of the items tested, 18% of the transactions were missing approvals or adequate supporting documentation of the time and expense allocated to the grant. Identification as a repeat finding This is not a repeat finding Recommendation We recommend CAP review its policies and procedures related to the internal controls over payroll, expenditures related to grants. Views of Responsible Officials CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. Payroll services were outsourced to ADP payroll services in order to provide real time features and accountability for time. This allows recording of time more accurate, reliable and allocable. Payroll records are reviewed and time studies are being performed for all staff to ensure allocation methodology, once selected is appropriate, consistent and in alignment with staff performance. Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. See Corrective Action Plan
2023-002 Activities Allowed or Unallowed and Allowable Costs/Costs Principles Program Community Services Block Grant Name of Contact Person Kelly Wessels, Executive Director Corrective Action Plan As of July 1, 2023 the following behaviors and standards were implemented: • CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. • Payroll services were outsourced to ADP payroll services in order to provide real time features and accountability for time. This allows recording of time more accurate, reliable and allocable. Payroll records are reviewed and time studies are being performed for all staff to ensure allocation methodology, once selected is appropriate, consistent and in alignment with staff performance. o Time entry occurs electronically in real time; hourly employees are assigned a schedule, and salaried staff are monitored o Time cards are electronically submitted and approved electronically to ensure time is recorded as it occurs. o Time off records are also submitted for approval electronically and leave is approved based on County personnel guidance. • Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: o Internal controls o Allowable compensation and employee benefits o Cost allocation methods o Governing body financial responsibilities o Budgeting o Financial reporting o Financial management systems o Documentation and record retention o Financial policies and procedures o Allowable costs • All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. Proposed Completion Date June 30, 2024
2023-003 Cash Management Program: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) Federal Assistance Listing No: 93.224 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Grant year: 2022 Federal Award Identification: Unknown Applicable Pass-through Entity: None Criteria When non-federal entities are funded under the reimbursement method, expenditures included in reimbursement requests should have supporting documentation and the entity should have paid for the costs for which the reimbursement is requested prior to the date of the reimbursement request. Condition Community Action Partnership of Natrona County (CAP) submitted reimbursement requests in excess of actual expenditures. Cause Due to turnover in grant management, processes that had previously existed were overlooked. A reconciliation of grant expenditures to the amounts requested for reimbursement was not performed resulting in reimbursements that were greater than the actual grant expenditures. Effect or potential effect Without adequate review and reconciliations of reimbursement requests, an entity may submit inaccurate expenditure reimbursement requests. Questioned Cost None Context We tested 24 out of 26 reimbursement requests submitted during the grant period by comparing each reimbursement request to the actual expenditures in the CAP general ledger. Additionally, we reconciled total grant reimbursements to total grant expenditures. We noted that total grant reimbursement requests exceeded the total grant expenditures by $9,473. Identification as a repeat finding This is not a repeat finding Recommendation We recommend CAP review its policies and procedures related to the internal controls over reimbursement requests to assure reimbursement requests have supporting documentation and reconcile to actual expenditures incurred. Views of Responsible Officials CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. Payroll services were outsourced to ADP payroll services in order to provide real time features and accountability for time. This allows recording of time more accurate, reliable and allocable. Payroll records are reviewed and time studies are being performed for all staff to ensure allocation methodology, once selected is appropriate, consistent and in alignment with staff performance. Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. See Corrective Action Plan
Show full finding ▾Hide full finding ▴2023-003 Cash Management Program: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) Federal Assistance Listing No: 93.224 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Grant year: 2022 Federal Award Identification: Unknown Applicable Pass-through Entity: None Criteria When non-federal entities are funded under the reimbursement method, expenditures included in reimbursement requests should have supporting documentation and the entity should have paid for the costs for which the reimbursement is requested prior to the date of the reimbursement request. Condition Community Action Partnership of Natrona County (CAP) submitted reimbursement requests in excess of actual expenditures. Cause Due to turnover in grant management, processes that had previously existed were overlooked. A reconciliation of grant expenditures to the amounts requested for reimbursement was not performed resulting in reimbursements that were greater than the actual grant expenditures. Effect or potential effect Without adequate review and reconciliations of reimbursement requests, an entity may submit inaccurate expenditure reimbursement requests. Questioned Cost None Context We tested 24 out of 26 reimbursement requests submitted during the grant period by comparing each reimbursement request to the actual expenditures in the CAP general ledger. Additionally, we reconciled total grant reimbursements to total grant expenditures. We noted that total grant reimbursement requests exceeded the total grant expenditures by $9,473. Identification as a repeat finding This is not a repeat finding Recommendation We recommend CAP review its policies and procedures related to the internal controls over reimbursement requests to assure reimbursement requests have supporting documentation and reconcile to actual expenditures incurred. Views of Responsible Officials CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. Payroll services were outsourced to ADP payroll services in order to provide real time features and accountability for time. This allows recording of time more accurate, reliable and allocable. Payroll records are reviewed and time studies are being performed for all staff to ensure allocation methodology, once selected is appropriate, consistent and in alignment with staff performance. Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. See Corrective Action Plan
2023-003 Cash Management Program Health Care for the Homeless Name of Contact Person Kelly Wessels, Executive Director Corrective Action Plan • CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. o All fiscal transactions are entered into Sage, and all backup is uploaded at the time of requested transaction. o This is then sent to the Approver, who then reviews for reasonable, allocable and allowable costs. o Payment requests cannot be submitted and forwarded electronically if the backup is not uploaded and the requestor electronically initials that they did so. Approvers are assigned in work flows and transactions are reviewed by Supervisor, Fiscal Department personal o Reimbursement requests are reviewed at program level, compliance officer level and fiscal and presented to Executive Director to review with backup before submitted for reimbursement. Sage houses all backup receipts etc. o All journal entries have time stamps in software and identify who/when the entry occurred and a field is provided to explain the “why”, with reference(s). • Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. • Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: o Internal controls o Allowable compensation and employee benefits o Cost allocation methods o Governing body financial responsibilities o Budgeting o Financial reporting o Financial management systems o Documentation and record retention o Financial policies and procedures o Allowable costs • All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. Proposed Completion Date June 30, 2024
FAC accepted this audit on January 22, 2023 — management decision was due July 22, 2023.
Significant Deficiencies in Internal Control Over Compliance Findings 2022-002 Procurement, Suspension and Debarment Program: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), Federal Assistance Listing No: 93.323 County Recipient: City of Casper/Natrona County Health Department Federal Agency: Department of Health and Human Services Federal Award Identification: None Applicable Pass-through Identification: None Pass-through entity: Wyoming Department of Health Criteria or Specific Requirement Suspension and Debarment ? Section 180.995 of the Code of Federal Regulations (CFR) indicates that when a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-federal entity must verify that the entity is not suspended and debarred or otherwise excluded from participating in the transaction. Internal controls should be designed and operating to ensure the requirements related to procurement, suspension and debarment are applied to any large purchase. Condition Internal controls over procurement, including the controls over entering into a transaction with a suspended or debarred party, were not followed on an applicable purchase. Health Department officials indicated that a search was performed however the results of the search were not maintained. The Health Department is responsible for following their procurement policies and maintaining evidence the policies were followed. Questioned Costs None. Context Out of the 3 transactions tested for procurement compliance, there was only one transaction over $25,000. For this transaction, no documentation was maintained regarding the pre-purchase search to determine the vendor was not suspended or debarred. Effect or Potential Effect Without full compliance with the requirements for procurement, suspended and debarred, the entity could be required to repay all amounts expended for these purchased. Cause After the search was performed no printout was maintained to document the search. Identification of a Repeat Finding No Significant Deficiencies in Internal Control Over Compliance Findings (Continued) Recommendation The City of Casper/Natrona County Health Department needs to improve their documentation in regards to SAM searches as well as insure that all appropriate languages are included in all contracts entered into regarding federal funds. Views of Responsible Officials See Corrective Action Plan
Show full finding ▾Hide full finding ▴Significant Deficiencies in Internal Control Over Compliance Findings 2022-002 Procurement, Suspension and Debarment Program: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), Federal Assistance Listing No: 93.323 County Recipient: City of Casper/Natrona County Health Department Federal Agency: Department of Health and Human Services Federal Award Identification: None Applicable Pass-through Identification: None Pass-through entity: Wyoming Department of Health Criteria or Specific Requirement Suspension and Debarment ? Section 180.995 of the Code of Federal Regulations (CFR) indicates that when a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-federal entity must verify that the entity is not suspended and debarred or otherwise excluded from participating in the transaction. Internal controls should be designed and operating to ensure the requirements related to procurement, suspension and debarment are applied to any large purchase. Condition Internal controls over procurement, including the controls over entering into a transaction with a suspended or debarred party, were not followed on an applicable purchase. Health Department officials indicated that a search was performed however the results of the search were not maintained. The Health Department is responsible for following their procurement policies and maintaining evidence the policies were followed. Questioned Costs None. Context Out of the 3 transactions tested for procurement compliance, there was only one transaction over $25,000. For this transaction, no documentation was maintained regarding the pre-purchase search to determine the vendor was not suspended or debarred. Effect or Potential Effect Without full compliance with the requirements for procurement, suspended and debarred, the entity could be required to repay all amounts expended for these purchased. Cause After the search was performed no printout was maintained to document the search. Identification of a Repeat Finding No Significant Deficiencies in Internal Control Over Compliance Findings (Continued) Recommendation The City of Casper/Natrona County Health Department needs to improve their documentation in regards to SAM searches as well as insure that all appropriate languages are included in all contracts entered into regarding federal funds. Views of Responsible Officials See Corrective Action Plan
2022-002 Procurement, Suspension and Debarment Program: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Name of Contact Person Anna Kinder, Executive Director Corrective Action Plan Casper Natrona County Health Department will review and update the current procurement policy dated 6/2018 to include updated fiscal language to ensure compliance with all funding requirements. Specifically, it will address the review and documentation by SAM.GOV to ensure the vendor is not suspended, debarred or not certified. A form will be developed and moving forward, it will be completed for all required and necessary purchases that are over the current threshold guidelines. It will include appropriate measures that are signed off by Finance and the Executive Director that verification and documentation have been completed as well as supporting documentation of competitive pricing from three sources when applicable. Proposed Completion Date June 30, 2023
FAC accepted this audit on January 19, 2022 — management decision was due July 19, 2022.
Significant Deficiencies in Internal Control Over Compliance Findings 2021-001 Procurement, Suspension and Debarment Program: Health Centers Cluster, Consolidated Health Centers - Health Care for the Homeless, Federal Assistance Listing No: 93.224 COVID-19 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Federal Award Identification: None Applicable Pass-through Identification: None Criteria Internal controls should be designed and operating to ensure the requirements related to procurement, suspension and debarment are applied to any large purchase. Condition Internal controls over procurement, including the controls over entering into a transaction with a suspended or debarred party, were not followed on an applicable purchase of a mobile unit. Questioned Costs None. Context Out of the 40 transactions tested for procurement compliance, there was only one high value transaction over $150,000. For this transaction, no pre-purchase search was made to determine the vendor was not suspended or debarred. Effect Without full compliance with the requirements for procurement, suspended and debarred, the entity could be required to repay all amounts expended for these purchased. Cause In an effort to quickly get a mobile unit in use to mitigate COVID related health issues among the homeless population, an internal control was sidestepped. Identification of a Repeat Finding No Recommendation Community Action Partnership needs to strengthen its commitment to maintaining the federally internal control structure even in challenging situations. Views of Responsible Officials and Planned Corrective Actions See Corrective Action Plan
Show full finding ▾Hide full finding ▴Significant Deficiencies in Internal Control Over Compliance Findings 2021-001 Procurement, Suspension and Debarment Program: Health Centers Cluster, Consolidated Health Centers - Health Care for the Homeless, Federal Assistance Listing No: 93.224 COVID-19 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Federal Award Identification: None Applicable Pass-through Identification: None Criteria Internal controls should be designed and operating to ensure the requirements related to procurement, suspension and debarment are applied to any large purchase. Condition Internal controls over procurement, including the controls over entering into a transaction with a suspended or debarred party, were not followed on an applicable purchase of a mobile unit. Questioned Costs None. Context Out of the 40 transactions tested for procurement compliance, there was only one high value transaction over $150,000. For this transaction, no pre-purchase search was made to determine the vendor was not suspended or debarred. Effect Without full compliance with the requirements for procurement, suspended and debarred, the entity could be required to repay all amounts expended for these purchased. Cause In an effort to quickly get a mobile unit in use to mitigate COVID related health issues among the homeless population, an internal control was sidestepped. Identification of a Repeat Finding No Recommendation Community Action Partnership needs to strengthen its commitment to maintaining the federally internal control structure even in challenging situations. Views of Responsible Officials and Planned Corrective Actions See Corrective Action Plan
2021-001 Procurement, Suspension and Debarment Program: Health Centers Cluster, Consolidated Health Centers - Health Care for the Homeless Name of Contact Person Marilyn Dymond Wagner, Executive Director Condition Internal controls over procurement, including the controls over entering into a transaction with a suspended or debarred party, were not followed on an applicable purchase of a mobile unit. Corrective Action Plan Management of Community Action Partnership of Natrona County and Healthcare for the Homeless are providing more education to staff on the need to perform and document the search for suspended and debarred parties. Proposed Completion Date June 30, 2022
FAC accepted this audit on January 14, 2021 — management decision was due July 14, 2021.
FAC accepted this audit on January 21, 2020 — management decision was due July 21, 2020.
Significant Deficiencies in Internal Control Over Compliance Findings 2019-001 Procurement Program: Health Centers Cluster, Consolidated Health Centers - Health Care for the Homeless, CFDA No: CFDA 93.224 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Federal Award Identification: None Applicable Pass-through Identification: None Criteria Non-Federal entities other than States, including those operating Federal programs as subrecipients of States, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable State and local laws and regulations, provided that the procurements conform to applicable Federal statutes and the procurement requirements identified in 2 CFR part 200. Condition The County has established procurement policies that meet the criteria described above. These policies are followed for all new procurement decisions and require documentation of the considerations in the procurement decision. Procurement decisions that were made in the past and vendor relationships established in the past are not fully documented as complying or being allowed exceptions to the procurement policies. Questioned Costs None. Context While few ongoing relationships such as those with software vendors and medical providers impact this program, they need to be documented within the terms of the current procurement policy. Effect Without this documentation, the County may find it hard to evidence full compliance with the federal procurement requirements. Cause As entities are improving compliance with the procurement regulations, consideration of relationships that were established before the current policies were established may or may not be fully considered. Identification of a Repeat Finding No Recommendation We recommend documenting the considerations inherent in the past procurement decisions to the extent they are known. Consideration of re-evaluation of the procurement decision may be needed. Views of Responsible Officials and Planned Corrective Actions See Corrective Action Plan
Show full finding ▾Hide full finding ▴Significant Deficiencies in Internal Control Over Compliance Findings 2019-001 Procurement Program: Health Centers Cluster, Consolidated Health Centers - Health Care for the Homeless, CFDA No: CFDA 93.224 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Federal Award Identification: None Applicable Pass-through Identification: None Criteria Non-Federal entities other than States, including those operating Federal programs as subrecipients of States, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable State and local laws and regulations, provided that the procurements conform to applicable Federal statutes and the procurement requirements identified in 2 CFR part 200. Condition The County has established procurement policies that meet the criteria described above. These policies are followed for all new procurement decisions and require documentation of the considerations in the procurement decision. Procurement decisions that were made in the past and vendor relationships established in the past are not fully documented as complying or being allowed exceptions to the procurement policies. Questioned Costs None. Context While few ongoing relationships such as those with software vendors and medical providers impact this program, they need to be documented within the terms of the current procurement policy. Effect Without this documentation, the County may find it hard to evidence full compliance with the federal procurement requirements. Cause As entities are improving compliance with the procurement regulations, consideration of relationships that were established before the current policies were established may or may not be fully considered. Identification of a Repeat Finding No Recommendation We recommend documenting the considerations inherent in the past procurement decisions to the extent they are known. Consideration of re-evaluation of the procurement decision may be needed. Views of Responsible Officials and Planned Corrective Actions See Corrective Action Plan
Community Action Partnership Corrective Action Plan Finding 2019-001 Name of Contact Person ? Marilyn Dymond Wagner, Executive Director Corrective Action CAPNC will document the procurement process regarding procurements for which the decision was made in prior years.
Significant Deficiencies in Internal Control Over Compliance Findings 2019-002 Special Tests and Provisions - Sliding Fee Discounts Program: Health Centers Cluster, Consolidated Health Centers - Health Care for the Homeless, CFDA No: CFDA 93.224 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Federal Award Identification: None Applicable Pass-through Identification: None Criteria Internal controls should be designed and operating to ensure the requirements related to sliding fee discounts are applied to fees for services provided to all individuals and families with incomes at or below 200% of the Federal Poverty Guidelines. Condition Internal controls over the sliding fee discount and input into the billing system were not properly designed or operating effectively. The information for all new patients was effectively reviewed as was the information for all patients recertifying in an annual recertification process. The information for all other patients receiving services was not reviewed. Questioned Costs None. Context Patient information used for determination of the sliding discount to be applied must be reviewed for accuracy. Effect Sliding fee discounts may have been provided to individuals in an incorrect amount and individuals entitled to lower fees may not have received them. Cause Due to limited staffing, information input into the system was not reviewed. Identification of a Repeat Finding Yes Recommendation Evidence of the review and approval should be retained. Patient information used for determination of the sliding discount should be carefully reviewed, with evidence of review as well. Views of Responsible Officials and Planned Corrective Actions See Corrective Action Plan
Show full finding ▾Hide full finding ▴Significant Deficiencies in Internal Control Over Compliance Findings 2019-002 Special Tests and Provisions - Sliding Fee Discounts Program: Health Centers Cluster, Consolidated Health Centers - Health Care for the Homeless, CFDA No: CFDA 93.224 County Recipient: Community Action Partnership of Natrona County Federal Agency: Department of Health and Human Services Federal Award Identification: None Applicable Pass-through Identification: None Criteria Internal controls should be designed and operating to ensure the requirements related to sliding fee discounts are applied to fees for services provided to all individuals and families with incomes at or below 200% of the Federal Poverty Guidelines. Condition Internal controls over the sliding fee discount and input into the billing system were not properly designed or operating effectively. The information for all new patients was effectively reviewed as was the information for all patients recertifying in an annual recertification process. The information for all other patients receiving services was not reviewed. Questioned Costs None. Context Patient information used for determination of the sliding discount to be applied must be reviewed for accuracy. Effect Sliding fee discounts may have been provided to individuals in an incorrect amount and individuals entitled to lower fees may not have received them. Cause Due to limited staffing, information input into the system was not reviewed. Identification of a Repeat Finding Yes Recommendation Evidence of the review and approval should be retained. Patient information used for determination of the sliding discount should be carefully reviewed, with evidence of review as well. Views of Responsible Officials and Planned Corrective Actions See Corrective Action Plan
Community Action Partnership Corrective Action Plan Finding 2019-002 Name of Contact Person ? Marilyn Dymond Wagner, Executive Director Corrective Action This was a finding issued in FY 2017; a process to address this issue was created in 2018. Although the process was utilized, the responsible staff members did not follow the process for documenting the required action. The process is as follows: Although there were no instances where our sliding fee scale was applied incorrectly, the new HRSA requirements require a process to verify that the sliding fee discount is both accurately entered into the Electronic Health Record AND accurately applied to each patient. In order to address his issue, we are establishing a system that requires the billing coordinators Electronic Health Record data entry to be verified. This will be completed by the 12th Street Clinic?s Operations Manager, no later than March 15 of each year prior to the sliding fee scale implementation April 1 of each year. A signed copy of this review will be maintained in a file to document the activity for the annual audit. In addition, the 12th Street Clinic case manager or Operations Manager will review each new client file in the electronic heath record to ensure that the EHR system is correctly applying the sliding fee discount to each patient. This activity will be documented in the notes section of the patients? health record. Finally, the board of directors will review the updated Poverty Guidelines each year at the February board meeting along with the updated sliding fee scale that corresponds to the new poverty guidelines. The board will approve the new sliding fee scale. The 12th Street Clinic billing coordinator will be given the approved sliding fee scale to input into the Electronic Health Record system. Because the process was implemented but not documented according to the outlined plan of action last year, all affected staff members will be given a copy of the plan of action, which will be reviewed in detail with the Executive Director. Each staff member will sign a statement at the bottom acknowledging that they have had the opportunity to review the plan of action and ask any questions for clarification. They further understand they are responsible for the FULL implementation of the process, which includes required documentation. This will be maintained in the personnel file.
2018-004
FAC accepted this audit on January 24, 2019 — management decision was due July 24, 2019.
GSA_MIGRATION
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GSA_MIGRATION
GSA_MIGRATION
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GSA_MIGRATION
2017-002
GSA_MIGRATION
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GSA_MIGRATION
2017-003
FAC accepted this audit on January 8, 2018 — management decision was due July 8, 2018.
GSA_MIGRATION
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GSA_MIGRATION
GSA_MIGRATION
Show full finding ▾Hide full finding ▴FAC accepted this audit on January 4, 2017 — management decision was due July 4, 2017.
GSA_MIGRATION
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GSA_MIGRATION
2015-003
GSA_MIGRATION
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GSA_MIGRATION
2015-003
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