Corrective Action Plans

Finding 390627 (2023-210)

Material Weakness 2023

State of Idaho

ID

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

Finding Number 2023-210: Low-Income Home Energy Assistance Program (LIHEAP) performance and special reports did not include a review for accuracy and compliance prior to submission. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Depar...

Finding Number 2023-210: Low-Income Home Energy Assistance Program (LIHEAP) performance and special reports did not include a review for accuracy and compliance prior to submission. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Program will develop a process to work with the Information Management and Analysis Team (IMAT) within the division to compile the data for the Low-Income Home Energy Assistance Program (LIHEAP) reports. Program will review the completed reports for accuracy. All reports will then be submitted to the Bureau Chief, as a second review of accuracy, prior to submission to Federal Partners. Documentation will be maintained to support the preparation, review, and approval steps. The process outlines a timeline to have reports prepared and reviewed ahead of the established deadline. Program will communicate with our Federal Partner if circumstances arise that would prevent a report from being submitted by an established deadline to receive an extension. Anticipated Corrective Action Date: The Program has already implemented the involvement of IMAT and secondary review and approval processes. Program will write a process document to support the corrective action. The documented process will be in place by April 15th, 2024. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390612 (2023-209)

Significant Deficiency 2023

State of Idaho

ID

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.416

Finding Number 2023-209: Monthly cost allocation statistics, used to allocate indirect costs to federal grants, were not reviewed and approved by the Department. Federal Programs: 10.551 - Supplemental Nutrition Assistance Program (SNAP) 10.561 - State Administrative Matching Grants for the Suppl...

Finding Number 2023-209: Monthly cost allocation statistics, used to allocate indirect costs to federal grants, were not reviewed and approved by the Department. Federal Programs: 10.551 - Supplemental Nutrition Assistance Program (SNAP) 10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (SNAP) 21.027 - Coronavirus State and Local Fiscal Recovery Funds 93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises 93.558 - Temporary Assistance for Needy Families (TANF) 93.568 - Low-Income Home Energy Assistance 93.569 – Adoption Assistance 93.575 - Child Care and Development Block Grant (CCDF 93.658 - Foster Care Title IV-E 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.778 - Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: With the implementation of Luma and the interfaced cost allocation module, finance has spent a significant amount of time assessing the best practices for cost allocation processing steps. Since going live on 7/1/23, each month, finance has reviewed, revised, and refined process steps. The department’s budget analysts who hold oversight of some cost allocation processes, use a spreadsheet to track processing. Finance has added a step in the process to ensure that finance reviews the cost allocation SharePoint site for review and signature of each supervisor responsible for each statistic. Anticipated Corrective Action Date: March 1, 2024 Responsible for Corrective Action: Staci Phelan, Division Administrator Staci.Phelan@dhw.idaho.gov 208-334-0632 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390597 (2023-206)

Significant Deficiency 2023

State of Idaho

ID

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.332

Finding Number 2023-206: The Department did not fully disclose required information to subrecipients, document subrecipient risk assessments, or ensure subrecipient audits were received for the Coronavirus State and Local Fiscal Recovery Fund. Federal Programs: 21.027 – Coronavirus State and Local ...

Finding Number 2023-206: The Department did not fully disclose required information to subrecipients, document subrecipient risk assessments, or ensure subrecipient audits were received for the Coronavirus State and Local Fiscal Recovery Fund. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The department agrees with the lack of certain required subrecipient information datapoints for the CSLFRF projects. • The department had an imperfect implementation of the initial subawards for CSLFRF documentation for subrecipients. Our general practice includes providing the identified federal award identification datapoints; however, this was not the case with the initial CSLFRF subrecipients. As an example, the period of performance was truncated to ensure that we were able to meet the aggressive timeline outlined in the American Rescue Plan Act; we will include both the true period of performance as set forth in the grant and the budgetary period in which the subrecipient will need to complete their work. Carrie Champlin, Contracts Manager, and Rob Sepich, Chief Financial Officer will implement these changes by April 15, 2024. • The department had processes for evaluating the risk of subrecipients, however it could be improved and made clearer for auditors and we will implement a process used by other agencies to memorialize the risk factors outside of email in a clear and concise manner. Additionally, the department is currently implementing a new software system, Amplifund, to aid in registering subrecipients, monitoring them, and closing out subawards. This system will include all of the relevant information necessary for both the subrecipient and the department in one location and will provide consistency across the department. Amplifund implementation is currently underway and will be used department- wide by August 2024. Doug McRoberts, Grants Manager, Jeri Ann Fogg, Accounting Manager, Carrie Champlin, Contracts Manager are working on the integration of Amplifund. Anticipated Corrective Action Date: April 15, 2024 Responsible for Corrective Action: Rob Sepich, Chief Financial Officer Rob.Sepich@deq.idaho.gov 208-373-0292

View Audit 301345

Finding 390548 (2023-002)

Material Weakness 2023

Turning Point of Central California, Inc.

CA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Material Weakness § 200.118 § 200.318 § 200.326

Finding 2023-002 Procurement Corrective Action: TPOCC has updated its Finance Manual, inclusive of a procurement policy in compliance with Uniform Guidance (2 CFR Part 200). We have also had all management staff who deal with programs funded by Federal Funds attend training on Uniform Guidance. We w...

Finding 2023-002 Procurement Corrective Action: TPOCC has updated its Finance Manual, inclusive of a procurement policy in compliance with Uniform Guidance (2 CFR Part 200). We have also had all management staff who deal with programs funded by Federal Funds attend training on Uniform Guidance. We will continue to have staff attend these training courses to ensure that they are familiar with the requirements of Uniform Guidance. We have also begun implementing a procurement system (Pairsoft Paramount Workplace) and anticipate a go live of April 1st, 2024. This will help ensure our procurement policies are implemented and followed uniformly. Person Responsible: Finance Director, Lacy Meneses and CFO, Will Goodall Timing for Implementation: Currently in progress and procurement software will Go Live on April 1st, 2024. Document ID: b51a2bdf940fc8367245121fabb689a6083edd8e9deb8925c16c8fec9313f6b8 Page 1 Summary Schedule of Prior Year Findings and Questioned Costs Turning Point of Central California, Inc. did not retain procurement records to support its assertion that it is contracting with vendors that provide the best prices. Turning Point of Central California, Inc. has not updated its procurement policy to comply with the Uniform Guidance (2 CFR Part 200). This finding was first reported in the June 30, 2021 audit, issued in June 2022, and Turning Point of Central California, Inc. did not have adequate time to implement its corrective action plan during the year ended June 30, 2023. Questioned Costs: None

View Audit 301300

Finding 390534 (2023-001)

Significant Deficiency 2023

Jacobs & Cushman San Diego Food Bank

CA

Questioned Costs Allowable Costs / Cost Principles

The Food Bank is aware of the issue brought to them by external auditors during the expense testing phase of the audit for the fiscal year ended June 30, 2023. The issue under review is that the indirect payroll costs did not follow the cost allocation plan for three quarters of the fiscal year. Sta...

The Food Bank is aware of the issue brought to them by external auditors during the expense testing phase of the audit for the fiscal year ended June 30, 2023. The issue under review is that the indirect payroll costs did not follow the cost allocation plan for three quarters of the fiscal year. Staff turnover within the finance department during the period contributed to this error. To avoid this error going forward, the Food Bank has filled open positions so that the department is fully staffed and has brought on a Chief Financial Officer. In addition, processes have been set in place for managerial review of allocations on a quarterly basis. Actions to correct the finding have been completed. For inquiries regarding this finding, please contact Allyson Tutor, CFO at 858-863-5114 who is responsible for the corrective action.

View Audit 301284 Questioned Costs: $1

Finding 390533 (2023-009)

Material Weakness 2023

Success Center San Francisco

CA

Questioned Costs Allowable Costs / Cost Principles

Response: CES subtracted previous Supportive Services costs that were not allowable in the December 31, 2023 quarterly report. CES has attached the supporting documentation that supports the correction of Supportive Services costs. CES reviewed the GPMS YB Participants Status and Contact Report, at...

Response: CES subtracted previous Supportive Services costs that were not allowable in the December 31, 2023 quarterly report. CES has attached the supporting documentation that supports the correction of Supportive Services costs. CES reviewed the GPMS YB Participants Status and Contact Report, attached in Appendix H, and compared the list to all the Participant on the books and removed any participant direct costs with attached Journal Entry, Appendix I.

View Audit 301283 Questioned Costs: $1

Finding 390518 (2023-001)

Significant Deficiency 2023

Community Action Partnership of Mercer County

PA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.403

March 27, 2024 Federal Audit Clearinghouse Re: Corrective Action Plan for Community Action Partnership of Mercer County To whom it may concern: Views of Responsible Officials and Planned Corrective Actions: 2023-01 There is no disagreement with the audit finding regarding costs allowed or allow...

March 27, 2024 Federal Audit Clearinghouse Re: Corrective Action Plan for Community Action Partnership of Mercer County To whom it may concern: Views of Responsible Officials and Planned Corrective Actions: 2023-01 There is no disagreement with the audit finding regarding costs allowed or allowable reviewed. The Organization’s fiscal policy manual policies and procedures states Audit costs are direct charged to each program and are billed separately to each program at a cost of 2% of the total budget of the program or grant. This policy has been enforced for years with an agreement between auditors and the organization. Management will review and update the Organization’s fiscal policy manual and procedures for consistency and compliance with GAAP and Uniform Guidance. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: May 31, 2024 Respectfully Submitted, Michelle Clarke VP/CFO

View Audit 301273 Questioned Costs: $1

Finding 390473 (2023-002)

Material Weakness 2023

Guthrie County Hospital

IA

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Department of Health and Human Services: Federal Financial Assistance Listing #93.498 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN #426037759 Activities Allowed or Unallowed and Allowable Costs/Cost Principles ...

Department of Health and Human Services: Federal Financial Assistance Listing #93.498 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN #426037759 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control Over Compliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: Guthrie County Hospital (the Hospital) reported expenses in the Department of Health and Human Services (HHS) special report for Period 4 that were not reduced by reimbursement from other sources or that other sources were obligated to reimburse. Additionally, the Hospital did not report its excess expenses as unreimbursed expenses attributable to Coronavirus in the HHS special report, did not report total interest earned on the ARP Rural Payments and Period 4 General Distribution Payments, and reported gross revenues/net charges from patient care by quarter for 2021 when net revenues should have been reported. In addition, there was no evidence retained that the HHS special report was reviewed by an individual separate from the preparer prior to submission. Planned Corrective Action: Management will implement an internal control policy for federal awards compliance to more diligently review the reporting of expenses and revenues to ensure all reporting requirements are met. However, had the errors in reporting of expenses and lost revenues been identified and corrected prior to reporting, the Hospital would have demonstrated that they had incurred eligible expenses and lost revenue in excess of the Period 4 funds received, including interest on such funds. Contact Person, Title and Phone Number: Christopher Stipe, Chief Executive Officer, (641)332-2201 Anticipated Date of Completion: June 30, 2024

View Audit 301254

Finding 390470 (2023-003)

Material Weakness 2023

The Be Kind People Project Foundation

AZ

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.303

2023‐003 Material Weakness in Internal Control over Compliance with Actvities Allowed Unallowed and Allowable Costs/Cost Principles Condition: The Organiza􀆟on did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing av...

2023‐003 Material Weakness in Internal Control over Compliance with Actvities Allowed Unallowed and Allowable Costs/Cost Principles Condition: The Organiza􀆟on did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing available. Management’s Response and Corrective Action Plan: The CEO will add a regular discussion point to the weekly finance meetings in which the finance department reports on both the status of federal funds and the expenditures using those funds. Responsible Individuals: -Maintain separate tracking account – Marcia Meyer, CEO, in conjunction with Board Finance Committee - Authorization for use of funds – Marcia Meyer - Maintenance of records for use – Jennie Myers - Confirmation with use of funds per allowable uses per national guidelines – Jennie Myers - Reporting on monthly finance report – Jennie Myers Anticipated Completion Date: This process is underway and will be visible at the fiscal year‐end audit in June 2024

View Audit 301253

Finding 390401 (2023-002)

Significant Deficiency 2023

Livingstone College

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Finding 2023-002 – U.S. Department of Education (USDE), Title IV Student Financial Aid Programs (Deficiency): We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs a) One (1) out of six (6) stu...

Finding 2023-002 – U.S. Department of Education (USDE), Title IV Student Financial Aid Programs (Deficiency): We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs a) One (1) out of six (6) students tested for R2T4 did not have Title IV funds returned to the Federal government within the required 45 days. Title IV HEA 34 CFR 668.22. b) The College was not reconciling between Financial Aid and Business Office on the monthly basis per SFA Handbook Ch. 5 CFR668.161-668.176. Auditor’s Recommendation – We recommend that the College ensure adequate documentation is obtained and kept on file as evidence that all expenditures meet allowable cost and other requirements under the grant program. Corrective Action – Management agrees with this finding. The College will place additional emphasis on the R2T4 of funds. Management is reviewing the timing of presentation of situations to Financial Aid that require returning funds to the Department. Additional focus will be placed on procedures to timely report withdraws to Financial Aid to support returned funds in the required 45 days. In addition, the College prepares monthly reconciliations between Financial Aid and the Business Office, but often delayed in completion. Going forward, the reconciliation will be noted on the monthly closing list and requires both the Assistant Vice President of Financial Aid and Controller to sign and date the reconciliation to demonstrate compliance with the monthly requirement.

View Audit 301203

Finding 390378 (2023-103)

Material Weakness 2023

Coconino County

AZ

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Cluster name: WIOA Cluster Assistance Listings number and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated complet...

Cluster name: WIOA Cluster Assistance Listings number and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completion date: June 30, 2024 Concur. The County Administration Department acknowledges the work experience (WEX) requirement was not met for the Workforce Innovation and Opportunity Act (WIOA) Youth Program Year 2021 allocation. The Department has a tracking mechanism in the financial system and other records to account for the percentage of youth expenditures made on WEX activities. Due to an oversight, the percentage of WEX expenditures in relation to the total allocation was not monitored by staff. Additionally, the amount of WEX funding allocated to the Youth program service provider was insufficient to meet the requirement. The Department will write procedures for the monitoring of earmarking requirements, including WEX, to ensure the roles and responsibilities of staff and key stakeholders are clearly defined. The calculation of funds allocated to the service provider will factor in the level of WEX expenditures needed for the County to meet the requirement. The Department will work with the WIOA Youth program service provider to employ best practices and strategies to recruit eligible in-school and out-of-school youth in need of WEX activities to further their skills and job readiness. The Department will monitor WEX expenditures made by the service provider and provide technical assistance as needed. If the Department projects the County will not meet the threshold for a certain program year allocation, it will seek technical assistance from the Arizona Department of Economic Security.

View Audit 301196 Questioned Costs: $1

Finding 390344 (2023-001)

Material Weakness 2023

Hawaii Pacific University

HI

Allowable Costs / Cost Principles § 200.303

For payroll-related expenditures, management reviewed the duties of individuals and estimated the percentage of their time allocable to the program based upon knowledge of office functions, job duties, and additional demands and tasks related to the COVID-19 pandemic. This review and discussions wit...

For payroll-related expenditures, management reviewed the duties of individuals and estimated the percentage of their time allocable to the program based upon knowledge of office functions, job duties, and additional demands and tasks related to the COVID-19 pandemic. This review and discussions within the management team resulted in the amounts allocated to the HEERF program; the percentage allocations assigned were documented in the calculations used to support the payroll activity recorded during the fiscal year ended June 30, 2023. For non-payroll related expenditures, documented policies were not developed for the HEERF program expenditures and as a result supporting justifications were not consistently documented or maintained. For all expenditures associated with the HEERF program, when documentation was not obtained or maintained, management was basing decisions on all regulations available at the time and decisions made did not violate the intent of the program. The HEERF awards were fully expended as of June 30th, 2022 for the Student Portion and as of September 30th, 2022 for the Institutional Portion. Should similar programs become available in the future, management will develop, in advance of expending funds, documented policies and procedures to administer the program and will maintain documentation demonstrating compliance with program requirements and related institutional policy and procedure. Person Responsible: Assistant Vice President for the Office of Sponsored Projects; Manager, Office of Sponsored Projects; Director of Financial Aid. Targeted Correction Date: n/a, program has ended. Fiscal Year in which Finding Initially Occurred: 2021 (Finding Number 2021-002).

View Audit 301190

Finding 390294 (2023-003)

Material Weakness 2023

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2023-003 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long B...

REFERENCE: 2023-003 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long Beach and Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: At St. Mary Medical Center – Long Beach, the leadership team implemented a timecard review process to ensure timecards are properly signed off and approved each pay period, with exceptions confirmed via email from the appropriate manager. At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders will be sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator will send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The executive director will ensure supervisory follow-up with each name that shows up in the audit report each pay period by Kronos Reports. Person Responsible: Vo Phay Sin, Controller – St. Mary Medical Center, Long Beach Rob Hays, Executive Director – Bailey Boushay House Expected Completion: April 2024

View Audit 301158

Finding 390290 (2023-002)

Significant Deficiency 2023

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2023-002 – Allowable Costs/Cost Principles Medical Assistance Program (Medicaid Cluster) (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Mercy San Juan Medical Center Finding: At Mercy San Juan Medical Center, internal controls ove...

REFERENCE: 2023-002 – Allowable Costs/Cost Principles Medical Assistance Program (Medicaid Cluster) (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Mercy San Juan Medical Center Finding: At Mercy San Juan Medical Center, internal controls over the required allowability criteria with regard to payroll expense were not performed for 2 of 25 employees selected for testing. Corrective Action Plan: In addition to timecard approval by supervisors, Mercy San Juan Medical Center Finance will review a sign-off report and obtain written approval via email for unapproved timecards. Person Responsible: Lianna Petrosyan, Director of Finance Expected Completion: April 2024

View Audit 301158

Finding 390226 (2023-002)

Significant Deficiency 2023

Do Good Multnomah

OR

Allowable Costs / Cost Principles Cash Management Reporting

We have implemented additional levels of approval and oversight for point-of-sale and invoice spending to ensure that receipts are captured and retained correctly, and that at invoices are reviewed and approved before payment. We have also provided additional training for spenders on best practices ...

We have implemented additional levels of approval and oversight for point-of-sale and invoice spending to ensure that receipts are captured and retained correctly, and that at invoices are reviewed and approved before payment. We have also provided additional training for spenders on best practices of recording and maintaining records. We have since also consolidated our supply chain so that spenders are able to procure most supplies through one vendor, which will have reporting and tracking capabilities. We will also be making significant changes to how mileage reimbursement is documented and approved.

View Audit 301123

Finding 390225 (2023-001)

Material Weakness 2023

Do Good Multnomah

OR

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

The finance team has been expanded and with the guidance of a nonprofit finance consultant additional roles are set to be established so that there is support to be able to be able to adequately review and approve invoices, as well as train and hold accountability with supervisors for payroll approv...

The finance team has been expanded and with the guidance of a nonprofit finance consultant additional roles are set to be established so that there is support to be able to be able to adequately review and approve invoices, as well as train and hold accountability with supervisors for payroll approval.

View Audit 301123

Finding 390194 (2023-001)

Material Weakness 2023

College Dreams, INC

OR

Allowable Costs / Cost Principles Cash Management Material Weakness

Finding # 2023-001 Material weakness over allowable costs U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Only allowable costs may be charged to the contract for reimbursement. One out of six invoices charged to the contract was an unallowable expense (sc...

Finding # 2023-001 Material weakness over allowable costs U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Only allowable costs may be charged to the contract for reimbursement. One out of six invoices charged to the contract was an unallowable expense (scholarships). Recommendation: Expenses charged to contract should be reviewed thoroughly and be in compliance with contract agreement. Management should have understanding of what costs are considered allowable and unallowable. Corrective Action: We will have the Executive Director, Business Manager and College+ Program Manager thoroughly review the monthly Talent Search billing before completing a drawdown to ensure that all expenses billed are allowable costs. Anticipated Completion Date: June 30, 2024

View Audit 301101

Finding 390193 (2023-002)

None 2023

University of Rochester

NY

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Finding 2023-002: (L) Reporting of Unreimbursed Expenses Attributable to Coronavirus and Lost Revenues within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing ...

Finding 2023-002: (L) Reporting of Unreimbursed Expenses Attributable to Coronavirus and Lost Revenues within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of Health and Human Services (HHS) Award Year: 1/1/2023-3/31/2023 Award Number: Not available Management’s Response to Finding: Management acknowledges the Period 4 HRSA Reporting portal submission errors noted. The personnel and supply costs identified at St. James Hospital and Memorial Hospital of William F and Gertrude F Jones Inc. were all allowable and reported in Period 4, but were over- or under-stated in a particular quarter. Management acknowledges that St. James Hospital understated its lost revenue in Reporting Period 4. Management’s Corrective Action Plan: The University is unable to amend the Reporting Period 4 submissions. HRSA has only provided guidance to providers with respect to how to account for unallowable expenses identified in prior reporting periods. The portal submission expense items identified were all allowable expenses, but under- or over- reported in a particular quarter of the Period 4 Reporting. The lost revenue calculation for St. James Hospital was an error in reporting. Since there is no ability to amend the Period 4 reporting for either of these entities, the University will ensure that it documents these corrections in case of future inquiries from the HRSA. As noted above, the URMC Office of the Chief Financial Officer, in support with the Office of University Audit, the Controller’s Office, and the University of Rochester Medical Center (URMC) Office of Integrity and Compliance, conducted enterprise-wide reviews of the HRSA Reporting portal submissions of all University affiliates in FY23 prior to submission to the HRSA. The University will continue to conduct enhanced reviews with respect to its future required portal submissions. Contact person: Adam Anolik, URMC Senior Vice President and CFO, Adam_Anolik@URMC.Rochester.edu

View Audit 301098

Finding 390192 (2023-001)

None 2023

University of Rochester

NY

Allowable Costs / Cost Principles Reporting

Finding 2023-001: (A) (B) Unallowed COVID-19 expenditures reported within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of...

Finding 2023-001: (A) (B) Unallowed COVID-19 expenditures reported within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of Health and Human Services (HHS) Award Year: 1/1/2020-6/30/2023 Award Number: Not available Management’s Response to Finding: Management acknowledges that certain COVID-19 expenditures were overstated in the Period 4 Reporting period HRSA portal submissions by the University of Rochester and Related Entities (“the University”). Management’s Corrective Action Plan: As provided in HRSA’s FAQs regarding Auditing and Reporting Requirements for Provider Relief Fund Payments, a provider is allowed to replace its unallowable expenses with its unreimbursed lost revenues in the reporting period in question if a provider is not required to report in subsequent reporting periods. None of the related entities with findings have future required HRSA portal submission. Both UR Medicine Home Care and Nicholas H. Noyes Memorial Hospital had unreimbursed lost revenue that exceeded the identified unallowable expenses in Reporting Period 4. In accordance with HRSA’s guidance, UR Medicine Home Care and Nicholas H. Noyes Memorial Hospital will replace the unallowable expenses with unreimbursed lost revenue. St. James Hospital did not report enough unreimbursed lost revenue to replace the unallowable expenses. However, St. James Hospital has identified additional allowable expenses and a miscalculated lost revenue amount for Reporting Period 4 that would exceed the identified unallowable expenses. Further, enterprise-wide, the University had unreimbursed lost revenue that far exceeded the identified unallowable expenses. As the University is unable to amend Reporting Period 4 for St. James Hospital, the University will document the additional allowable expenses and miscalculated lost revenue amount in case of future inquiries. The URMC Office of the Chief Financial Officer, in support with the Office of University Audit, the Controller’s Office, and the University of Rochester Medical Center (URMC) Office of Integrity and Compliance, distributed enterprise-wide guidelines in FY23 to assist each entity with respect to allowable COVID-19 expenditures to help ensure reporting was complete and accurate. The University also conducted enterprise-wide reviews of the HRSA Reporting portal submissions of all University affiliates prior to submission to the HRSA. The University will continue to conduct enhanced reviews with respect to its future required portal submissions.

View Audit 301098

Finding 390169 (2023-002)

Material Weakness 2023

Capital Region Medical Center

MO

Questioned Costs Allowable Costs / Cost Principles Reporting

Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1,...

Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1, 2024.

View Audit 301083 Questioned Costs: $1

Finding 390165 (2023-006)

Material Weakness 2023

Yukon Flats School District

AK

Allowable Costs / Cost Principles Material Weakness

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: Management will ensure that the system of internal controls over cash disbursements is designed appropriately and operates effectively to ensure all transactions are coded, reviewed, and approved before payment is mad...

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: Management will ensure that the system of internal controls over cash disbursements is designed appropriately and operates effectively to ensure all transactions are coded, reviewed, and approved before payment is made. The Business manager and the Superintendent will conduct a review of claims to determine whether they are proper and valid charges. Once reviewed, all transactions will be authorized. DocuSign will be used for electronic signature approval. Accounts payable clerk will ensure that all transactions include copies of receipts for the goods or services purchased. Finally, the Finance department will work with the program directors to ensure that expenses are coded accurately and within reasonable timeframe to allow for timely submission of grant reports. Proposed Completion Date: March 31, 2024

View Audit 301080

Finding 390157 (2023-002)

Significant Deficiency 2023

City of Daly City

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430

Finding Reference Number: SA2023-002 Documenting Payroll Costs Charged to Grant Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Departm...

Finding Reference Number: SA2023-002 Documenting Payroll Costs Charged to Grant Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-22-MC-06-0010 COVID-19 - B-20-MW-06-0010 • Fiscal Year of Initial Finding: 2023 • Name(s) of the contact person: Betsy ZoBell, Housing and Community Development Manager • Corrective Action Plan: ECD staff will perform periodic review of estimates to confirm that payroll allocations are supported by timesheet documentation of actual hours worked. • Anticipated Completion Date: 06/30/24

View Audit 301060

Finding 390146 (2023-002)

Material Weakness 2023

Health Care for All, INC

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Given the Organization’s lack of experience with federal awards, Management was not familiar with the accounting requirements for expenses allocated to federal grant programs. In particular, there was a lack of familiarity with respect to the limitations on indirect cost rate application on subreci...

Given the Organization’s lack of experience with federal awards, Management was not familiar with the accounting requirements for expenses allocated to federal grant programs. In particular, there was a lack of familiarity with respect to the limitations on indirect cost rate application on subrecipient disbursements. Moving forward, management will ensure that it properly allocate expenses in accordance with Uniform Guidance Regulations. In addition, management plans to work closely with the federal passthrough entity to ensure that overbilled amounts are returned during the fiscal year ending June 30, 2024

View Audit 301052 Questioned Costs: $1

Finding 390145 (2023-001)

Significant Deficiency 2023

Health Care for All, INC

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with the Uniform Guidance. This exercise is anticipated to be complete by the end of the fiscal year.

View Audit 301052

Finding 390133 (2023-001)

Significant Deficiency 2023

Sunnyside Unified School District No. 12

AZ

Allowable Costs / Cost Principles § 200.230 § 200.430

Finding Number: 2023‐001 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425U, 84.425W Contact Person: Andrea Leon Foster, Director of Federal Programs Anticipated Completion Date: June 30, 2024 Planned Corrective Action: Although th...

Finding Number: 2023‐001 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425U, 84.425W Contact Person: Andrea Leon Foster, Director of Federal Programs Anticipated Completion Date: June 30, 2024 Planned Corrective Action: Although the Federal Programs Department has a process for periodic certification, compression was not included in the percentage breakdown for each classified staff salary. Reporting adjustments have been made to include ESSER funded positions with additional oversight on percentage breakdowns for positions funded with multiple cost objectives. These breakdowns are reflected in the electronic version of FORMS B and D in addition to the hard copies. The Federal Programs Director will work with district leadership to ensure all employees in each department (Curriculum and Instruction, Professional Development, etc.) on the process of maintaining Time and Effort logs and signing the bi‐annual FORM B and FORM D.

View Audit 301015

Corrective Action Plans

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