URBAN INDIAN CENTER OF SALT LAKENon-Profit

U. S. Department of Health and Human Services 2024-002 Allowable Costs Program(s) Name of Federal Program (Assistance Listing Number) Urban Indian Health Services (93.193) Special Diabetes Program for Indians - Diabetes Prevention and Treatment Projects (93.237) Criteria - Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non-Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services for the programs identified above. Context and Condition - We selected 41 paychecks from several pay periods to test for compliance with standards in these two programs. Records for eight of the paychecks tested lacked documentation of approval of the employee’s supervisor. Cause - The Organization replaced its payroll processing servicer subsequent to 2024. Access to certain records from the prior servicer were no longer available. Personnel turnover resulting in inconsistencies in maintaining required documentation. Effect - A federal program could be charged compensation for employees who did not provide services directly attributable to the program or charged for goods/services not related to the program. Questioned Costs - No costs were questioned. Repeat finding - Yes Statistically valid - Yes Recommendation - We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job-costing system implemented. Views of responsible officials - The Organization believes the paychecks identified were approved prior to payment. We will ensure that documentation is downloaded each pay period to ensure such documentation is not lost when a change in servicer is made.

U.S. Department of Health and Human Services 2024-003 Cash Management/Reporting Program(s) Name of Federal Program (Assistance Listing Number) Urban Indian Health Services (93.193) Special Diabetes Program for Indians - Diabetes Prevention and Treatment Projects (93.237) Criteria - Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Context and Condition - We compared four quarterly Federal Cash Transaction Reports and three monthly reimbursement requests to total disbursements reported by these two programs in the Organization’s job-costing system. In all cases, we found that the amounts requested did not match the amounts in the job-costing system. Cause - Due to increased funding the Organization received to address the impact of COVID-19, disbursements were not always correctly assigned to a program when incurred. Requests for federal funds were made based on those incomplete reports that were changed subsequently and no longer represent the amounts requested. The original reports were not maintained to support the requests made. Effect - A federal program could disburse funds prior to the disbursement by the Organization. We identified that both programs had requested funds in excess of disbursements. Questioned Costs - No costs were questioned. Repeat finding - Yes Statistically valid - Yes Recommendation - We recommend the Organization 1) maintains timely and accurate recording of disbursements in its job-costing system and 2) regularly request grant funds based on amounts expended as report in the Organization’s job-costing system. Views of responsible officials - The Organization is implementing a grant tracking system in addition to its job-costing system to better comply with these requirements. Together, these systems will be used to request only the amount attributable to the program for reimbursement.

U. S. Department of Health and Human Services 2023-002 Allowable Costs Program(s) Name of Federal Program (Assistance Listing Number) Urban Indian Health Services (93.193) Special Diabetes Program for Indians - Diabetes Prevention and Treatment Projects (93.237) Criteria - Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non-Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services for the programs identified above. Context and Condition - We selected 29 paychecks from several pay periods to test for compliance with standards in these two programs. Records for five of the paychecks tested lacked documentation of approval of the employee’s supervisor. Cause - The Organization replaced its payroll processing servicer subsequent to 2023. Access to certain records from the prior servicer were no longer available. Personnel turnover resulting in inconsistencies in maintaining required documentation. Effect - A federal program could be charged compensation for employees who did not provide services directly attributable to the program or charged for goods/services not related to the program. Questioned Costs - No costs were questioned. Repeat finding - Yes Statistically valid - Yes Recommendation - We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job-costing system implemented. Views of responsible officials - The Organization believes the paychecks identified were approved prior to payment. We will ensure that documentation is downloaded each pay period to ensure such documentation is not lost when a change in servicer is made.

U.S. Department of Health and Human Services 2023-003 Cash Management/Reporting Program(s) Name of Federal Program (Assistance Listing Number) Urban Indian Health Services (93.193) Special Diabetes Program for Indians - Diabetes Prevention and Treatment Projects (93.237) Criteria - Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Context and Condition - We compared four quarterly Federal Cash Transaction Reports and three monthly reimbursement requests to total disbursements reported by these two programs in the Organization’s job-costing system. In both reports we found that the amounts requested did not match the amounts in the job-costing system. Cause - Due to increased funding the Organization received to address the impact of COVID-19, disbursements were not always correctly assigned to a program when incurred. Requests for federal funds were made based on those incomplete reports that were changed subsequently and no longer represent the amounts requested. The original reports were not maintained to support the requests made. Effect - A federal program could disburse funds prior to the disbursement by the Organization. We identified that both programs had requested funds in excess of disbursements. Questioned Costs - No costs were questioned. Repeat finding - Yes Statistically valid - Yes Recommendation - We recommend the Organization 1) maintains timely and accurate recording of disbursements in its job-costing system and 2) regularly request grant funds based on amounts expended as report in the Organization’s job-costing system. Views of responsible officials - The Organization is implementing a grant tracking system in addition to its job-costing system to better comply with these requirements. Together, these systems will be used to request only the amount attributable to the program for reimbursement.

U. S. Department of Health and Human Services 2022-002 Allowable Costs Program(s) Name of Federal Program (Assistance Listing Number) Urban Indian Health Services (93.193) Special Diabetes Program for Indians - Diabetes Prevention and Treatment Projects (93.237) Criteria - Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non-Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services for the programs identified above. Context and Condition - We selected 27 paychecks from three pay periods to test for compliance with standards in these two programs. Records for six of the paychecks tested lacked documentation of approval of the employee’s supervisor. We also selected 16 transactions for purchased goods and services to test compliance with standards in these two programs. Records for two transactions tested lacked documentation of approval by the program director. Cause - The Organization replaced its payroll processing servicer subsequent to 2022. Access to certain records from the prior servicer were no longer available. Personnel turnover resulting in inconsistencies in maintaining required documentation. Effect - A federal program could be charged compensation for employees who did not provide services directly attributable to the program or charged for goods/services not related to the program. Questioned Costs - No costs were questioned. Repeat finding - No Statistically valid - Yes Recommendation - We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job-costing system implemented. Views of responsible officials - The Organization believes the paychecks and purchases identified were approved prior to payment. We will ensure that documentation is downloaded each pay period to ensure such documentation is not lost when a change in servicer is made.

U.S. Department of Health and Human Services 2022-003 Cash Management/Reporting Program(s) Name of Federal Program (Assistance Listing Number) Urban Indian Health Services (93.193) Special Diabetes Program for Indians - Diabetes Prevention and Treatment Projects (93.237) Criteria - Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Context and Condition - We compared two quarterly Federal Cash Transaction Reports to total disbursements reported by these two programs in the Organization’s job-costing system. In both reports we found that the amounts requested did not match the amounts in the job-costing system. Cause - Due to increased funding the Organization received to address the impact of COVID-19, disbursements were not always correctly assigned to a program when incurred. Requests for federal funds were made based on those incomplete reports that were changed subsequently and no longer represent the amounts requested. The original reports were not maintained to support the requests made. Effect - A federal program could disburse funds prior to the disbursement by the Organization. We identified that both programs had requested funds in excess of disbursements. Questioned Costs - No costs were questioned. Repeat finding - Yes Statistically valid - Yes Recommendation - We recommend the Organization 1) maintains timely and accurate recording of disbursements in its job-costing system and 2) regularly request grant funds based on amounts expended as report in the Organization’s job-costing system. Views of responsible officials - The Organization is implementing a grant tracking system in addition to its job-costing system to better comply with these requirements. Together, these systems will be used to request only the amount attributable to the program for reimbursement.

2021-001 Cash Management/Reporting Program(s) Name of Federal Program (CFDA Number) Good Health and Wellness in Indian Country (93.479) Emergency Grants to Address Mental and Substance Use Disorders During COVID-19 (93.665) Criteria - Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Context and Condition - We compared two quarterly Federal Cash Transaction Reports to total disbursements reported by these two programs in the Organization?s job-costing system. In both reports we found that the amounts requested did not match the amounts in the job-costing system. Cause - Due to increased funding the Organization was provided to address COVID-19- related issues, disbursements were not always correctly assigned to a program when incurred. Requests for federal funds were made based on those incomplete reports that were changed subsequently and no longer represent the amounts requested. The original reports were not maintained to support the requests made. Effect - A federal program could disburse funds prior to the disbursement by the Organization. We identified that both programs had requested funds in excess of disbursements. Questioned Costs - No costs were questioned. Repeat finding - No Statistically valid - Yes Recommendation - We recommend the Organization 1) maintains timely and accurate recording of disbursements in its job-costing system and 2) regularly request grant funds based on amounts expended as report in the Organization?s job-costing system. Views of responsible officials - The Organization will review its job-costing system policies and internal controls and request only the amount attributable to the program for reimbursement.

U.S. Department of Health and Human Services 2020-001 Allowable Costs Program(s) - Behavioral Health Education and Training Grants (93.243) Urban Health Services (93.193) Criteria - Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation charged to a federal program. ?Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: ?(iii) reasonable reflect the total activity for which the employee is compensated by the non- Federal entity? 2 CFR section 200.430(i). The Organization?s processes do not maintain sufficient documentation of the total activity of each employee for the programs identified above. Context and Condition - We selected 33 paychecks from three pay periods to test for compliance with standards in these two programs. Records for 21 of the paychecks tested lacked documentation sufficient to detail the total activity of the employee. Cause - The Organization implemented a job costing system during 2020 to document the daily activities of employees, but not all programs implemented this system fully. Effect - A federal program could be charged compensation for employees who did not provide services directly attributable to the program. Questioned Costs - No costs were questioned. Repeat finding - Yes Statistically valid - Yes Recommendation - We recommend the Organization ensure it 1) maintains records of each employee?s activity and 2) monitors compliance with the job-costing system implemented. Views of responsible officials - The Organization will review its job-costing system policies and internal controls and ensure timely action is taken when noncompliance is identified.

Criteria: The Organization determines a time allocation for each employee based upon budget and time spent on various contracts and grants. The Organization then manually allocates payroll expenses based upon these predetermined time allocations. Condition: It was noted in the audit procedures that internal control procedures are not always followed to properly allocate salaries and wages to the contracts as documented in the accounting and personnel records. Cause: Staff and supervisory personnel with insufficient knowledge and failure to follow established procedures to properly monitor the allocation of salaries and wages. Effect: Allocation of salaries and wages that is inconsistent with time allocations documented in accounting and personnel files. Recommendation: We recommend that the Organization review their controls of the payroll processes. If necessary, update policies and procedures to ensure that changes in time allocation are documented and maintained for future reference.

Criteria: Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires that cost must be adequately documented to demonstrate that only costs for allowable activity or allowable costs are charged to federal programs. Documentation should also support allocation of center-wide costs among the various programs within the Organization. Condition: Costs were charged to programs without documentation to support the allowability of costs, or if they were incurred prior to submission for reimbursement. Cause: The Organization did not have adequate internal controls to ensure documentation was maintained to support costs charged to federal programs. Effect: Unallowed costs may have been incurred under the federal programs. Context/Sampling: A sample of 45 disbursements among the major programs was made with exceptions noted in three instances, for which costs could not be substantiated as allowable or allocated to programs based on actual use. Recommendation: We recommend the Organization enhance internal controls to ensure adequate supporting documentation is always maintained to support allowability of Federal expenditures and whether expenditures are incurred before being submitted for reimbursement.

Criteria: Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires that cost must be incurred prior to request for reimbursement. Condition: Costs were duplicated through the accounting system, with purchase orders being issued but not updated for actual costs or purchases. This resulted in duplicated expenditures being recorded in the accounting system as they relate to credit card charges. Cause: The Organization did not have adequate internal controls to ensure the costs included in cost reimbursement requests were not duplicated. Effect: It is reasonably possible that costs that are not incurred were charged to federal programs. Context/Sampling: In our review of activity on credit card statements it was found that 10 transactions were duplicated and incorrectly part of the reimbursement requests made in the 2019 year. Recommendation: We recommend the Organization enhance internal controls to ensure adequate supporting documentation is always maintained to whether expenditures are incurred before being submitted for reimbursement.

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