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Not-for-profit board members need to wear many hats for the organization they serve. Every board member begins their term with a different set of skills, often chosen specifically for those unique abilities. As board members, we often assist the organization in raising money and as such, it is important for all members of the board to be fluent in the language of fundraising. Here are some basic definitions you need to know, and the differences between them

A capital campaign is a big undertaking. During the planning stage of a capital campaign you need to not only focus on your donor outreach strategy, but also on outreach materials. 

Good fundraising and good accounting do not always seamlessly align. While they all feed the same mission, fundraisers work to meet revenue goals while accountants focus on recording transactions in compliance with accounting standards. 

Read this if you are responsible for cybersecurity at your organization. 

During the financial audit process auditors are required to develop and confirm their understanding of Information Technology (IT) and cybersecurity practices as it relates to financial reporting to better understand risks and because of auditors’ heavy reliance on data pulled from accounting information systems. As auditors, we have seen a significant increase in the amount of impactful incidents affecting not-for-profit organizations and our IT security experts often share valuable advisory comments in annual audit communications with our clients. With recent incidents and a very rapidly changing business environment, here are the three most important from the last six months that impact all not-for-profits. 

Board oversight of cybersecurity 

Cybersecurity gaps within an organization’s systems may lead to risk exposure and have material impacts on all aspects of operations. Responsibility for cybersecurity controls and for establishing a culture of awareness and security should come from the Board and senior leadership. Board members and senior leaders should stay apprised of cybersecurity efforts on a regular basis and incidents should be summarized and reported on a quarterly basis. 

The Board should also consider adding a member who is a professional with IT and cybersecurity experience to help manage and understand the specific risks to the organization and help drive and support cybersecurity efforts.

Ransomware threats and preventive controls

The use of ransomware as a profitable attack on organizations by hackers continues to rapidly increase. Within the last year there have been multiple high-profile incidents that illustrate the impact of a successful attack. These impacts fall into two main areas. One impact may be financial, as millions of dollars are paid to the bad actors as ransom in hopes of being able to regain control of systems. The second impact is operational, resulting in a loss of control of systems and data during the event. Potentially, an unsuccessful data restoration could result in the total loss of information and data maintained on your networks. 

Though no organization may be able to prevent a ransomware attack from occurring entirely, there are basic cybersecurity controls that help reduce the likelihood and impact of an attack. Preventive controls may include: 

  • Security awareness training on phishing emails and overall IT security practices for all organization users
  • Multi-factor authentication 
  • Access controls that prevent users from installing unapproved software onto organization-owned workstations and networks
  • Anti-malware software installed on devices that connect to organization systems 
  • Use of Zero Trust data management tools for backups
  • Disabling macros in emails (prevents back-end processes from automatically running) 

In addition to including these preventive controls to your cybersecurity program, your organization should assess current corrective controls already in place to react to a ransomware event if one is detected or reported. Corrective controls may include:

  • Disaster recovery plans/business continuity plans 
  • Incident response plans
  • Backup controls and restoration tests 

As the risk of ransomware continues to increase and the types of attacks continue to increase in sophistication, your organization should consider regular assessments of IT controls and cybersecurity practices on a regular basis. Such assessments may be performed in conjunction with annual financial statement audits as an expanded scope and/or as a separate annual IT assessment. 

COVID-19 IT considerations 

The global COVID-19 pandemic significantly impacted nearly every aspect of modern life, including the way we work. As personnel were sent home and literally became a remote workforce overnight, changes to IT systems and controls rapidly adjusted to accommodate this new way of business. 

Where controls and procedures were adjusted, if not suspended, your organization should review those changes and determine if controls should revert back to the pre-pandemic process—or be formally changed and documented as policy. 

Guidance from the American Institute of Certified Public Accountants (AICPA) dictates that a gap in controls associated with the pandemic is not a legitimate reason for not completing a control and that any changes must be documented and properly managed.  

Well over a year into the pandemic, the concept of a hybrid workforce has emerged as the predominant way employees and businesses want to work. Your organization should review current policies and procedures that may pre-date the pandemic to ensure that the updates both document and consider the current business environment. 

Additionally, with personnel working remotely or in a hybrid model, or a combination of both, you should assess practices for managing remote access and a hybrid workforce and, where needed, implement industry best-practice tools and procedures to accommodate a remote workforce while maintaining security controls. If you have questions regarding you cybersecurity procedures or want to learn more, please contact our team. We’re here to help. 
 

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Cybersecurity update for organizations: Considerations for boards and senior management

Read this if you are a Chief Financial Officer, Chief Compliance Officer, FINOP, or charged with governance of a broker-dealer.

The results of the Public Company Accounting Oversight Board’s (PCAOB) 2020 inspections are included in its 2020 Annual Report on the Interim Inspection Program Related to Audits of Brokers and Dealers. There were 65 audit firms inspected in 2020 by the PCAOB and, although deficiencies declined 11% from 2019, 51 firms still had deficiencies. This high level of deficiencies, as well as the nature of the deficiencies, provides insight into audit quality for broker-dealer stakeholders. Those charged with governance should be having conversations with their auditor to see how they are addressing these commonly found deficiencies and asking if the PCAOB identified any deficiencies in the auditor’s most recent examination. 

If there were deficiencies identified, what actions have been taken to eliminate these deficiencies going forward? Although the annual report on the Interim Inspection Program acts as an auditor report card, the results may have implications for the broker-dealer, as gaps in audit quality may mean internal control weaknesses or misstatements go undetected.

Attestation Standard (AT) No. 1 examination engagements test compliance with the financial responsibility rules and the internal controls surrounding compliance with the financial responsibility rules. The PCAOB examined 21 of these engagements and found 14 of them to have deficiencies. The PCAOB continued to find high deficiency rates in testing internal control over compliance (ICOC). They specifically found that many audit firms did not obtain sufficient, appropriate evidence about the operating effectiveness of controls important to the auditor’s conclusions regarding the effectiveness of ICOC. This insufficiency was widespread in all four areas of the financial responsibility rules: the Reserve Requirement rule, possession or control requirements of the Customer Protection Rule, Account Statement Rule, and the Quarterly Security Counts Rule.

The PCAOB also identified a firm that included a statement in its examination report that referred to an assertion by the broker-dealer that its ICOC was effective as of its fiscal year-end; however, the broker-dealer did not include that required assertion in its compliance report.

AT No. 2 review engagements test compliance with the broker-dealer’s exemption provisions. The PCAOB examined 83 AT No. 2 engagements and found 19 of them to have deficiencies. The most significant deficiencies were that audit firms:

  • Did not make required inquiries, including inquiries about controls in place to maintain compliance with the exemption provisions, and those involving the nature, frequency, and results of related monitoring activities.
  • Similar to AT No. 1 engagements, included a statement in their review reports that referred to an assertion by the broker-dealer that it met the identified exemption provisions throughout the most recent fiscal year without exception; however, the broker-dealers did not include that required assertion in their exemption reports.

The majority of the deficiencies found were in the audits of the financial statements. The PCAOB did not examine every aspect of the financial statement audit, but focused on key areas. These areas were: revenue, evaluating audit results, identifying and assessing risks of material misstatement, related party relationships and transactions, receivables and payables, consideration of an entity’s ability to continue as a going concern, consideration of materiality in planning and performing an audit, leases, and fair value measurements. Of these areas, revenue and evaluating audit results had the most deficiencies, with 45 and 27 deficiencies, or 47% and 26% of engagements examined, respectively.

Auditing standards indicate there is a rebuttable presumption that improper revenue recognition is a fraud risk. In the PCAOB’s examinations, most audit firms either identified a fraud risk related to revenue or did not rebut the presumption of revenue recognition as a fraud risk. These firms should have addressed the risk of material misstatement through appropriate substantive procedures that included tests of details. The PCAOB noted there were instances of firms that did not perform any procedures for one or more significant revenue accounts, or did not perform procedures to address the assessed risks of material misstatement for one or more relevant assertions for revenue. The PCAOB also identified deficiencies related to revenue in audit firms’ sampling methodologies and substantive analytical procedures. Other deficiencies of note, that were not revenue related, included:

  • Incomplete qualitative and quantitative disclosure information, specifically in regards to revenue from contracts with customers and leases.
  • Missing required elements from the auditor’s report.
  • Missing auditor communications:
    • Not inquiring of the audit committee (or equivalent body) about whether it was aware of matters relevant to the audit.
    • Not communicating the audit strategy and results of the audit to the audit committee (or equivalent body).
  • Engagement quality reviews were not performed for some audit and attestation engagements.
  • Audit firms assisted in the preparation of broker-dealer financial statements and supplemental information.

Although there have been improvements in the amounts of deficiencies found in the PCAOB’s examinations, the 2020 annual report shows that there is still work to be done by audit firms. Just like auditors should be inquiring of broker-dealer clients about the results of their most recent FINRA examination, broker-dealers should be inquiring of auditors about the results of their most recent PCAOB examination. Doing so will help broker-dealers identify where their auditor may reside on the audit quality spectrum. If you have any questions, please don’t hesitate to reach out to our broker-dealer services team.

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2020 Annual Report on the Interim Inspection Program Related to Audits of Brokers and Dealers

Read this if you are working on ESG initiatives at your organization.

Whether you are a director or an executive well into the journey of developing and communicating your company’s strategic sustainability plans or in early stages, the rising public demand for environmental, social, and governance (ESG) reporting is becoming a force that cannot be ignored by boards and management teams.

ESG overview: reminders and FAQs

What does ESG information comprise? The term “ESG” reporting, used broadly, covers qualitative discussions of topics and quantitative metrics used to measure a company’s performance against ESG risks, opportunities, and related strategies. ESG, sustainability, and corporate social responsibility are terms often used interchangeably to describe nonfinancial reporting being shared publicly by companies. Such information is not currently subject to a singular authoritative set of standards.

What are examples of ESG and sustainability information? The following do not represent all-inclusive lists and, while some ESG information may be measured quantitatively, there are often many means to calculate metrics or information that may be difficult to quantify and therefore may be expressed qualitatively and described as such: 

As corporate ESG activities increase in relevance and importance to stakeholders, companies are seeking to both understand the complex landscape of ESG disclosure and reporting and determine the best path forward. This includes identifying, collecting, sharing, and improving upon qualitative and quantitative metrics reflecting long-term, strategic ESG value creation.

Organizations are in various stages of readiness to report on such decision-useful information. Currently, a myriad of reporting frameworks and wide variations in how companies choose to publicly share ESG information exist, making the ESG landscape complex to navigate. However, two things are certain:

  1. The pressure for companies to publicly disclose their approach to sustainability and ESG reporting continues to mount from a broad variety of stakeholders, and 
  2. ESG is rapidly rising to the forefront of boardroom agendas.

We have prepared the following to provide useful reminders, FAQs, and insights for those charged with governance as they consider the rapidly changing current ESG reporting landscape and evolving regulatory developments.

Is there a single authoritative set of ESG reporting standards? 

There are currently several frameworks and standards in use globally by companies to report on ESG, many of which may be complementary and used in combination for external reporting. Some of the more commonly used frameworks are: Sustainability Accounting Standards Board (SASB); Global Reporting Initiative (GRI); Task Force on Climate-Related Financial Disclosures (TCFD); International Integrated Reporting Council (IIRC); and Climate Disclosures Standards Board (CDSB). While many of these may already be complementary to each other, there is also growing support for a singular, global set of reporting standards for ESG, though the timing to achieve the necessary convergence remains uncertain.

Are U.S. companies required to disclose ESG information? 

Outside of certain industry regulators, such as required reporting by the Environmental Protection Agency on greenhouse gas emissions, implementation by U.S. companies remains voluntary. However, pressure from institutional investors—BlackRock, State Street and Vanguard—is mounting in support of companies providing ESG disclosures that align with both the SASB and TCFD frameworks. Additionally, sustainability risk issues are increasingly integrated into organizational risk frameworks such as COSO’s Enterprise Risk Management (ERM) framework.

Companies must also assess whether other ESG information, such as climate risk disclosures, are required under current MD&A disclosure rules. For example, if the risk represents a known trend or uncertainty the company reasonably expects will have a material impact on the company’s results of operations or capital resources, additional disclosure would be required.

What companies are reporting, and what information are they reporting? 

ESG disclosures vary significantly depending on the nature of the business, geography, industry, and stakeholder base, as well as available resources to devote to ESG. The largest global public companies have led the way in external ESG reporting and engagement, but this reporting is rapidly expanding to encompass smaller public entities and private entities. Companies of all sizes are both feeling the pressure to produce ESG reporting and identifying it as a means to differentiate themselves in the market by proactively conveying their corporate stories and strategies.

As noted in a recent White & Case study of proxy statements and filed 10-Ks for the top 50 companies by revenue in the Fortune 100, the following ESG categories showed the most significant increase in disclosures from the prior year:

  • Human capital management (HCM)
  • Environmental
  • Corporate culture
  • Ethical business practices
  • Board oversight of environment & social (E&S) issues
  • Social impact/community
  • E&S issues in shareholder engagement

The study noted that a majority of E&S disclosures in the SEC filings were qualitative and did not provide quantitative metrics. However, disclosures pertaining to environmental, HCM, and E&S goals, along with social impact and community relations were more likely to contain quantitative metrics.

Where do companies report ESG information? The most common places companies are providing public ESG disclosures include:

  • Standalone reports including corporate social responsibility (CSR)/sustainability reports
  • Company websites and marketing materials
  • MD&A sections of annual and quarterly reports
  • Earnings calls
  • Proxy statements and 8-Ks

Evolving auditor ESG attestation

Many of the metrics and qualitative disclosures around ESG information are not “governed” by an established framework such as generally accepted accounting principles (GAAP), and thus, may not be subject to the same rigor of processes and controls over such processes to ensure the integrity and accuracy of the underlying data and the appropriateness of the decisions and judgments being made by management in reporting on such information. For example, the fear of corporate “green or impact washing”—the incentive to make stakeholders believe that a company is doing more to promote ESG activities, particularly environmental protections, than it actually is—has left many stakeholders questioning the reliability, consistency, and accuracy of company ESG reporting. As ESG reporting continues to evolve and become a significant consideration for boards, investors, employees, suppliers, lenders, regulators, and others in making business decisions, there is a growing focus on the value of assurance on such information provided by independent third parties.

Type of attestation services to be provided

Determining the scope and level of assurance to be provided will vary based on company objectives in presenting ESG information, management’s readiness, and intended users and uses of ESG information. Attest services may include:

  • Examination: Consists of an examination performed by an auditor resulting in an independent opinion indicating whether the ESG information is in accordance with the agreed upon criteria, in all material respects. An examination engagement is the closest equivalent to the reasonable assurance obtained in an audit of financial statements.
  • Review: Consists of limited procedures, performed by an auditor, that result in limited assurance. The objective of a review engagement is for the auditor to express a conclusion about whether any material modifications should be made to the ESG information in order for it to be in accordance with the agreed upon criteria. Review engagements are substantially less in scope than examination engagements.


The ESG journey: first steps for boards just beginning the ESG reporting journey

The AICPA and Center for Audit Quality (CAQ) have issued a roadmap for audit practitioners laying out initial steps for those organizations and their boards who are in the beginning phases of the ESG reporting journey:

  • Conduct a materiality or risk assessment to determine which ESG topics are prioritized as important or “material” to the organization, its investors and other stakeholders
  • Implement appropriate board oversight of material ESG matters
  • Integrate/align material ESG topics into the ERM process
  • Integrate ESG matters into the overall company strategy
  • Implement effective internal control over ESG data collection, processing, and reporting


For boards considering an attestation engagement

The CAQ has further prepared the following questions boards may consider for companies that have already started reporting on ESG and may be considering an attestation engagement:

  • What is the purpose and objective of the attestation engagement on ESG information?
  • Who are the intended users of the ESG information and related attestation report?
  • Why do the intended users want or need an attestation report on the ESG information?
  • What are the potential risks associated with a misstatement or omission in the ESG information?
  • Does the company have a clear understanding what ESG information the intended users want or need to be in the scope of the attestation engagement?
  • What level of attestation service (examination or review engagement) will help the company achieve its objective?

Additional questions for board members to consider regarding their company’s preparedness for reporting include:

  • Does management have well established controls, policies, and procedures for the collection of and disclosure of ESG information? Are there gaps to be addressed?
  • Has the board, along with management, set specific objectives and goals for external reporting of ESG information?
  • Is the information disclosed by the company consistent across its various communication channels?
  • Are the ESG responsibilities at the board level clearly defined among appropriate committees and are those responsibilities directly linked to corporate strategic ESG goals and external reporting needs?
  • Have the right advisors been identified to assist in preparing for reporting and/or to attest to the quality of reporting?

Next steps

We encourage management, audit committees, and other board members to continue to educate themselves on the evolving landscape of ESG and carefully consider the needs of various stakeholders broadly when mapping out their ESG reporting needs. Particular attention should be paid to regulatory developments in this area.

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ESG reporting: Considerations for boards and those charged with governance

Read this if you are a plan sponsor of employee benefit plans.

This article is the eleventh in a series to help employee benefit plan fiduciaries better understand their responsibilities and manage the risks of non-compliance with Employee Retirement Income Security Act (ERISA) requirements. You can read the previous articles here.

Most employee benefit plans have outsourced a significant portion of the internal controls to a service organization, such as a third-party administrator. The plan administrator has a fiduciary responsibility to monitor the internal controls of the service organization and to determine if the outsourced controls are suitably designed and effective.

SOC 1 reports: Internal controls and financial reporting

Generally, the most efficient way to obtain an understanding of the outsourced controls is to obtain a report on controls issued by the service organization’s auditor. Commonly referred to as a System and Organization Controls (SOC) report, the SOC report should be based on the American Institute of Certified Public Accountants’ (AICPA) attestation standards and should cover internal controls relevant to financial reporting, also known as a SOC 1 report (the “1” indicating it covers internal controls over financial reporting).

Plan sponsors should perform a documented review of the SOC 1 report for each of the plan’s significant service organizations. The documented review should include the plan sponsor’s assessment of the complementary user entity controls outlined in the SOC 1 report. The complementary user entity controls are internal control activities that should be in place at the plan sponsor to provide reasonable assurance that the controls tested at the service organization are operating effectively at your plan. If a service organization’s internal controls are operating effectively, but complementary user entity controls are not in place at your organization, the effectiveness of the service organization’s internal controls may not transfer to your plan’s operations.

Creditability and CPA firms: Considerations

Creditability of the CPA firm completing the SOC 1 report examination may impact the reliability of the CPA firm’s opinion and thus your reliability on the service organization’s internal controls. Unfamiliarity with the service auditor’s qualifications may be mitigated through additional research. Items to consider are: 

  • The firm’s expertise in SOC 1 reporting
    • Are they familiar with the service organization’s industry?
    • How many professionals do they have that perform SOC 1 examination services?
  • The evaluation of AICPA peer reviews 
    Audit firms are required to have a periodic peer review conducted. The results of the peer review are public knowledge and can be found on the AICPA’s website.
    • Did the service auditor receive a “pass” rating during their most recent peer review?
    • Did the peer review cover SOC 1 examination services?
  • Evaluation of the service organization’s due diligence procedures surrounding the selection of an auditor

Some of this information may be readily available via the service auditor’s website, while other information may need to be gathered through direct communication with the service organization. A qualified service auditor should be able to provide a SOC 1 report that contains sufficient detail, relevant transactional activity, relevant control objectives, and a timely reporting period.

SOC 1 reports may contain an unqualified, qualified, adverse, or disclaimer of opinion. The report determines if the controls in place are adequate for complete and accurate financial reporting. Report qualifications may affect the risk of relying on the service organization and may result in the need for additional procedures or safeguards to help ensure the plan’s financial statements are presented fairly. Even if the SOC 1 report received an unqualified opinion, you should review the controls tested by the service auditor and the results of such testing for any exceptions. Exceptions, even if they don’t result in a qualified opinion, may have an impact on the plan’s control environment. 

You should also review the scope of the audit to check that all significant transaction cycles, processes, and IT applications were properly assessed for their impact on the plan’s financial statements. Areas outside the scope of the SOC 1 report may require additional consideration, including the possibility of obtaining more than one SOC 1 report for subservice organizations whose functions were carved out from the service organization’s SOC 1 report.

Subservice organizations

Subservice organizations are frequently utilized to process certain transactions or perform certain functions at the service organization. Management of the service organization may identify certain transaction cycles and processes that are performed by a subservice organization and choose to exclude relevant control objectives and related controls from the SOC 1 report description and the scope of the auditor’s engagement. In such cases, multiple SOC 1 reports may need to be acquired to gain adequate coverage of all controls and objectives relevant to your plan. 

Furthermore, you need to consider the time period the SOC 1 report covers. Coverage should be obtained for your plan’s full fiscal year. For SOC 1 reports that lack coverage of your plan’s full fiscal year, a bridge letter should be obtained to help ensure that no significant changes in controls occurred between the SOC 1 report examination period and the end of your plan’s fiscal year.

Although plans commonly outsource a significant portion of their day-to-day operations to service organizations, plan fiduciaries cannot outsource their responsibilities surrounding the maintenance of a sound control environment. SOC 1 reports are a great resource to assess the control environments of service organizations. However, such reports can be lengthy and daunting to review. We hope this article provides some best practices in reviewing SOC 1 reports. If you have any questions, or would like to receive a copy of our SOC 1 report review template, please don’t hesitate to reach out to our Employee Benefits Audit team.

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Service organizations and review of SOC 1 reports: Considerations and recommendations

Read this if you are a Skilled Nursing Facility (SNF) providing services to Medicare beneficiaries.

Skilled Nursing Facility (SNF) bad debt expenses resulting from uncollectible Medicare Part A and Part B deductible and coinsurance amounts for covered services are reimbursable under the Medicare Program on a full-utilization Medicare cost report. SNF providers can report allowable Medicare bad debt expense on Worksheet E, form CMS-2540-10. Currently Medicare reimburses 65% of the allowable amount, less sequestration, if applicable.  

BerryDunn maintains a database of SNF as filed Medicare cost reports nation-wide. We analyze data annually, looking for trends and opportunities to help providers optimize available reimbursement. Cost reports data shows that in 2018–2020, on average, 75% of facilities nation-wide reported allowable bad debts, and claimed, on average, close to $63,000 of reimbursable bad debts for Medicare Part A. 

To compare facilities of different sizes and Medicare utilization rate, we also show bad debts on per Medicare patient day basis (figure 2). In FY 2020, all US regions experienced an increase in reimbursable Medicare Part A debt, averaging $19.43 per Medicare patient day.  

Understanding the requirements for bad debts and utilizing this reimbursing opportunity could help your facility’s bottom line. 

Medicare bad debt checklist now available

To support SNFs with reimbursement for these costs, BerryDunn’s healthcare consulting team has developed a checklist that provides insight into the Medicare cost report opportunities. 

Download the checklist, and please contact us if you have any questions about your specific situation or would like to learn more.

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Medicare bad debt: Review sample procedures for Skilled Nursing Facilities