Corrective Action Plans

Finding 383024 (2023-117)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Student Financial Aid Allowable Costs / Cost Principles Subrecipient Monitoring

Corrective Action Plan: The Office of Student Financial Success has worked with the Office of Information Technology to deliver student loan disbursement information via the student portal. A tab has been created that allows students to receive specific disbursement information related to their stud...

Corrective Action Plan: The Office of Student Financial Success has worked with the Office of Information Technology to deliver student loan disbursement information via the student portal. A tab has been created that allows students to receive specific disbursement information related to their student loans. In addition, the disbursement notification process has been established to ensure all students receive a disbursement notification before disbursements are made to student accounts. Our policy now requires, before disbursement, the generation of disbursement notifications made by the Senior Systems Analyst. Implementation Date: January 2024 Responsible Person: Dr. Latisha Addison, Executive Director Student Financial Success Corrective Action Plan: The University has implemented significant process enhancements in this area. The University has updated the charges associated with the university installment plan in the ERP system to be designated as an unallowable charge. This update will ensure that Title IV aid will not pay towards those charges. Management will conduct a second level review to ensure that the University is in compliance with the requirements. Implementation Date: February 2024 Responsible Person: Mr. Errol Thomas, Executive Director of Student Accounting

View Audit 296491

Finding 383008 (2023-004)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Corrective action plan: Program is enhancing processes to reconcile current expenses and ensure only eligible expenses are reported on the applicable funding sources. These actions will result in accurate amounts reported on the schedule of federal award expenditures. To strengthen requirements rela...

Corrective action plan: Program is enhancing processes to reconcile current expenses and ensure only eligible expenses are reported on the applicable funding sources. These actions will result in accurate amounts reported on the schedule of federal award expenditures. To strengthen requirements related to unique disaster funding, DSHS will reevaluate all invoices on this grant to ensure they are on the proper funding source. The State Medical Operations Center Finance staff will coordinate with DSHS Financial Division to communicate FEMA updates impacting expense reimbursement. Implementation date: August 31, 2024 Responsible persons: Wayne Zwart, Disaster Finance Manager, Center for Health Emergency Preparedness and Response’; Amanda Hudson, Budget Director, Financial Division

View Audit 296491 Questioned Costs: $1

Finding 382995 (2023-016)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303 § 200.308 § 200.403

Corrective action plan: HHSC completed the correction of the rate prior to year-end close on August 25, 2023. General Ledger Cost Allocation Team will work with CFO Operations Support to develop a query to identify journal transactions that post in the CAPPS Financials general ledger module before t...

Corrective action plan: HHSC completed the correction of the rate prior to year-end close on August 25, 2023. General Ledger Cost Allocation Team will work with CFO Operations Support to develop a query to identify journal transactions that post in the CAPPS Financials general ledger module before the project start date. This query will be run monthly and any exceptions will be corrected. An additional review of the new fiscal year payroll projects will be performed by both Budget and the General Ledger Chartfield teams as part of annual fiscal year close coordination. Implementation date: August 31, 2024 Responsible person: Heather Nevill, Director, Fund Management

View Audit 296491 Questioned Costs: $1

Finding 382987 (2023-015)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Subrecipient Monitoring Eligibility Special Tests & Provisions § 200.303 § 200.334

Corrective action plan: In December 2021, the Texas Health and Human Services Commission (HHSC) implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidatio...

Corrective action plan: In December 2021, the Texas Health and Human Services Commission (HHSC) implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information). Children’s Health Insurance Program (CHIP) provider enrollment, revalidation, and re-enrollment documentation, including risk-based screenings, are tracked in PEMS. Additionally, the relevant federal databases are checked at least monthly for all providers currently enrolled in CHIP. Of the CHIP providers requested during the fiscal year 2023 Statewide Single Audit, 59 of 60 samples had been enrolled or revalidated through PEMS and the auditor received all requested documentation. The listed exceptions only apply to one CHIP provider. The provider enrolled with CHIP before the implementation of PEMS. HHSC operated under the public health emergency (PHE) between March 30, 2020, and May 11, 2023. In response to the public health emergency (PHE), the Centers for Medicare and Medicaid Services waived exclusion check requirements for provider reenrollments and revalidations. HHSC is in the process of revalidating providers through PEMS; however, as a result of the PHE end date and provider revalidation requirements, the projected completion date for the required revalidation of all CHIP providers is January 2027. HHSC continues efforts to enroll CHIP providers through PEMS and expects to eliminate errors related to these documents once all CHIP providers have revalidated. Implementation dates: December 2021, PEMS implementation January 2027, provider enrollment and revalidation completed Responsible persons: Jordan Nichols, Deputy Associate Commissioner, Medicaid and CHIP Services Operations Management

View Audit 296491

Finding 382984 (2023-013)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303 § 200.334

Corrective action plan: The HHSC Federal Funds Office will work with HHSC Accounting, Department of Family and Protective Services (DFPS), and Texas Workforce Commission (TWC) to strengthen oversight of the Social Services Block Grant (SSBG) post-expenditure report. As part of this oversight, HHSC w...

Corrective action plan: The HHSC Federal Funds Office will work with HHSC Accounting, Department of Family and Protective Services (DFPS), and Texas Workforce Commission (TWC) to strengthen oversight of the Social Services Block Grant (SSBG) post-expenditure report. As part of this oversight, HHSC will compile procedure documents, methodologies, data sources, and work documents from DFPS and TWC. The HHSC Federal Funds Office already has this documentation for HHSC. Implementation date: August 31, 2024 Responsible person: Racheal Kane, Director, Federal Funds

View Audit 296491

Finding 382927 (2023-020)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective action plan: The Office of the Governor, Public Safety Office (PSO) has Policy 8.60 User Accounts that includes the periodic review of internal and external users in eGrants every six (6) months. This eGrants User Account Review is the responsibility of the PSO eGrants Help Desk. In Novem...

Corrective action plan: The Office of the Governor, Public Safety Office (PSO) has Policy 8.60 User Accounts that includes the periodic review of internal and external users in eGrants every six (6) months. This eGrants User Account Review is the responsibility of the PSO eGrants Help Desk. In November 2022, the lead System Support Specialist for the PSO retired from state service with over 20 years of service to the OOG. Due to her knowledge of the eGrants system, she was assigned the responsibility of completing the eGrants User Access Review; and, prior to her departure she completed a review that covered the January – June 2022 review period. After her departure, the eGrants User Access Review responsibility was assigned to the eGrants Help Desk but was not placed on the Master Tasklist used by the Desk to track compliance and reporting deadlines. This led to the July – December 2022 User Access Review not being completed. To ensure the eGrants User Access Review is completed in a timely manner and in accordance with our internal policy, this task has been added to the PSO Master Tasklist with a due date of July 31 for the January – June review period and January 31 for the July – December review period. In December 2023, the eGrants Help Desk completed the January 2023 – June 2023 user account review; the July 2023 – December 2023 review was completed on February 1, 2024. In December 2023 the PSO’s Grants Administration Director trained two PSO Help Desk staff on the User Account Review processes to mitigate issues with staff vacancies. This task will be monitored by the PSO’s Grants Administration Director. Implementation date: December 18, 2023 Responsible persons: Angie Martin, Public Safety Office Grants Administration Director, and Public Safety Office eGrants Help Desk Staff

View Audit 296491

Finding 382926 (2023-019)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective action plan: The OOG updated and documented the Change Management Procedures for Portal systems for all Portals subsequent to TTIR. The OOG began using Super Clio (the internally developed Change Management tracking system) for new projects and Portals, subsequent to TTIR, in accordance w...

Corrective action plan: The OOG updated and documented the Change Management Procedures for Portal systems for all Portals subsequent to TTIR. The OOG began using Super Clio (the internally developed Change Management tracking system) for new projects and Portals, subsequent to TTIR, in accordance with the new Change Management Procedure. Please see attached Change Management Procedure for OOG Information Services Division Portal systems. TTIR is a portal system that was created for a limited purpose and will decommission in the summer of 2024. The OOG will include the TTIR decommissioning project under the Change Management Procedure and mandate use of Super Clio. OOG Management does not anticipate further changes will be done to TTIR code, hotfixes applied, or content changes will be made. Any exceptions to this will be documented, approved, and signed by Management and put in the TTIR Program file for future evidence. Implementation date: Full implementation March 1, 2024 Responsible persons: Suzanne Johnson, Director of Administration, and Lars Hjaltman, Director of Information Services Division

View Audit 296491

Finding 382925 (2023-008)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.334

Corrective action plan: The Provider Finance Department (PFD) will take proactive measures to establish and enforce guidelines that guarantee documentation is retained for a minimum of three years from the date of submission of the final expenditure report for each grant. This approach aligns with o...

Corrective action plan: The Provider Finance Department (PFD) will take proactive measures to establish and enforce guidelines that guarantee documentation is retained for a minimum of three years from the date of submission of the final expenditure report for each grant. This approach aligns with our dedication to transparency, accountability, and responsible grant management. We will ensure that all the documentation is saved within our documentation repository for a minimum of three years from the date of submission. Implementation date: June 1, 2024 Responsible person: Stacy Kerns – Director, Business Operations and Support Services

View Audit 296491 Questioned Costs: $1

Finding 382922 (2023-026)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles § 200.302 § 200.303

Corrective action plan: TDHCA will enhance internal controls over reporting by implementing a secondary review to compare reported amounts to supporting documentation. Standard Operating Procedures will be updated to include secondary review. The formula that led to this error has already been corre...

Corrective action plan: TDHCA will enhance internal controls over reporting by implementing a secondary review to compare reported amounts to supporting documentation. Standard Operating Procedures will be updated to include secondary review. The formula that led to this error has already been corrected. Implementation date: March 31, 2024 Responsible person: David Johnson, HAF/TRR Data & Reporting Manager

View Audit 296491

Finding 382916 (2023-006)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Corrective action plan: The GLO will review the process and task notes templates to correct the language to ensure it differentiates between those that have TIGR access and those that do not, and properly reflects what was reviewed and completed with an offboarding request. In addition, the GLO will...

Corrective action plan: The GLO will review the process and task notes templates to correct the language to ensure it differentiates between those that have TIGR access and those that do not, and properly reflects what was reviewed and completed with an offboarding request. In addition, the GLO will review the account de-provisioning process in place to determine if it can be improved to address the account access that was available after this individual left the agency. The GLO will implement a semi-annual manual or automated account review process to identify accounts for former employees who were not properly disabled with their departure from the agency. This process will be documented as part of our overall user access review processes. Implementation date: May 15, 2024 Responsible persons: Robert Eason, Deputy Director, CDR, Pamela Mathews, Director Program Integration, CDR, Brad Kaufman, Senior Director of IT Operations.

View Audit 296491

Finding 382915 (2023-005)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Corrective action plan: The GLO will update the Active Directory password policy for GLOAD domain users to align it to the agency password policy as defined in GLO Identification and Authentication policy. We are unable to add the same password policy complexity and lockout settings to the on-premis...

Corrective action plan: The GLO will update the Active Directory password policy for GLOAD domain users to align it to the agency password policy as defined in GLO Identification and Authentication policy. We are unable to add the same password policy complexity and lockout settings to the on-premises, standalone MIP system as this software doesn’t provide that functionality. Implementation date: May 15, 2024 Responsible person: Brad Kaufman, Senior Director of IT Operations.

View Audit 296491

Finding 382913 (2023-009)

Significant Deficiency 2023

State of Texas C/o Comptroller of Public Accounts

TX

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

Corrective action plan: The General Ledger Cost Allocation and Chartfield teams are currently fully staffed. An aggressive plan to complete FY 2023 reallocations and catch FY 2024 reallocations up to current (one federal quarter plus one month in arrears) is in place. Implementation date: August 31,...

Corrective action plan: The General Ledger Cost Allocation and Chartfield teams are currently fully staffed. An aggressive plan to complete FY 2023 reallocations and catch FY 2024 reallocations up to current (one federal quarter plus one month in arrears) is in place. Implementation date: August 31, 2024 Responsible person: Heather Nevill, Director, Fund Management

View Audit 296491 Questioned Costs: $1

Finding 382896 (2023-003)

Significant Deficiency 2023

Corona-Norco Unified School District

CA

Questioned Costs Allowable Costs / Cost Principles

The District has implemented training and a review process related to indirect cost requirements for federal programs.

View Audit 296464 Questioned Costs: $1

Finding 382868 (2023-008)

Significant Deficiency 2023

Northeast School Corporation

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2023-008 Information on the federal program: Subject: Special Education Cluster (IDEA) - Earmarking Federal Agency: Department of Education Federal Program: Special Education Grants to States Assistance Listings Number: 84.027 Federal Award Numbers: 22611-022-PN01 Pass-Through Entity: Indian...

FINDING 2023-008 Information on the federal program: Subject: Special Education Cluster (IDEA) - Earmarking Federal Agency: Department of Education Federal Program: Special Education Grants to States Assistance Listings Number: 84.027 Federal Award Numbers: 22611-022-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Matching, Level of Effort, Earmarking Audit Findings: Significant Deficiency Condition: The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the earmarking requirements. The Cooperative did not have adequate procedures in place to ensure that the required level of expenditures for non-public school students with disabilities was met for each member school. The Cooperative did not have effective internal controls to ensure non-public school expenditures were appropriately identified and reported. Context: The School Corporation is a member of the Greene Sullivan Special Education Cooperative (Cooperative). During fiscal year 2022-2023, the Cooperative operated the special education programs and spent the federal money on behalf of all its members. As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Matching, Level of Effort, Earmarking compliance requirement. Although the Cooperative has a separate object code to identify expenditures for the purpose of proportionate share, there is no identifier or separate way to track which member school the funding was expended for. As such, the Non-Public Proportionate Share expenditures for the 22611-022-PN01 grant award could not be verified for the individual member schools. Additionally, the Cooperative did not obtain a waiver from the Indiana Department of Education for the 22611-022-PN01 grant award, no waiver was obtained, and the amounts spent could not be traced to documentation that indicated which member school the expenditure was applied to. Also, the total amount expended for proportionate share was less than the total amount required when all member school proportionate share requirements were totaled. The lack of internal controls and noncompliance were isolated to the 22611-022-PN01 grant award. The minimum earmarking requirement for the 22611-022-PN01 grant award was $1,620. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action: 1 – Northeast School Corporation will establish a system of internal controls and procedures to ensure non-public proportionate share funds are appropriately allocated to the member school based on expenses charged directly on behalf of the member school. Supporting documentation for these expenses should be retailed for audit. 2 – Greene Sullivan Special Education Cooperative will require all staff to complete the appropriate google form following the completion of each session with Non-Public students. An example of this documentation is the Proportionate Share Service Log. This document will allow for ease of tracking funds per provider/school district. This will allow for successful usage of funds. In the event that funds are not successfully used, a waiver will be requested barring board approval. Responsible party and timeline for completion: Mark A Baker, Superintendent Effective April 2024

View Audit 296449

Finding 382835 (2023-005)

Material Weakness 2023

Northeast School Corporation

IN

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

FINDING 2023-005 Information on the federal program: Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Pre...

FINDING 2023-005 Information on the federal program: Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listings Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (or Other Identifying Numbers): 19611-022-PN01, 20611-022-PN01, 21611-022-PN01, 22611-022-PN01, 22611-022-ARP, 23611-022-PN01, 20619-022-PN01, 21619-022-PN01, 22619-022-PN01, 22619-022-ARP, 23619-022-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Audit Finding: Material Weakness, Qualified Opinion Condition: The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The Cooperative had not designed or implemented adequate policies or procedures to determine that grant expenditures were for the excess costs of providing special education and related services to children with disabilities, were in conformance with the applicable cost principles and were obligated during the award period of performance. There was no documented oversight, review, or approval process in place at the Cooperative to ensure expenditures were allowable, conformed with cost principles and were incurred during the period of performance. Context: The School Corporation is a member of the Greene-Sullivan Special Education Cooperative (Cooperative). During fiscal year 2021-2022 and 2022-2023, the Cooperative operated the special education programs and spent the federal money on behalf of all its members. As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The Cooperative had not designed or implemented adequate policies or procedures to determine that grant expenditures were for the excess costs of providing special education and related services to children with disabilities, were in conformance with the applicable cost principles and were obligated during the award period of performance. There was no documented oversight, review, or approval process in place at the Cooperative to ensure expenditures were allowable, conformed with cost principles and were incurred during the period of performance. The lack of internal controls was a systemic issue throughout the audit period. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action: The Superintendent and Treasurer of Northeast School Corporation will review the documentation for the Cooperative at least semi-annually. Responsible party and timeline for completion: Mark A Baker, Superintendent Angel Riley, Treasurer April 2024

View Audit 296449

Finding 382826 (2023-003)

Material Weakness 2023

North White School Corporation

IN

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.305

FINDING 2023-003 Information on the federal program: Subject: Education Stabilization Fund – Advance Draws Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identif...

FINDING 2023-003 Information on the federal program: Subject: Education Stabilization Fund – Advance Draws Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425D210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs- Cost Principles Audit Finding: Material Weakness, Other Matters Condition: The School Corporation requested reimbursement prior to incurring expenditures under federal grant awards. An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed or Unallowed, Allowable Costs- Cost Principles compliance requirements. Context: During testing disbursements charged to ESF grants, we noted the ESSER I grant award, tracked in Fund 7940, and the ESSER III grant award, tracked in Fund 7932, had a positive cash balance of $2,718 and $35,661, respectively, at June 30, 2023 as a result of advance payments received during fiscal year 2023. The School Corporation submitted a request for reimbursement on November 15, 2022 for $21,745 from the ESSER I grant award and $565,876 from the ESSER III grant award, respectively. These requests for reimbursements were partially supported by disbursements incurred as of the date of the request, however, partially include requests for advance payments that were still not fully expended as of June 30, 2023. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. If there are any posting corrections after a reimbursement has been made and received, the Corporation Treasurer will contact IDOE (Indiana Department of Education) asking whether they would like the difference between the reimbursement and the new disbursement amount paid back to DOE or spent down within a specific time period. Responsible Party and Timeline for Completion: The Corporation Treasurer, Emma Conwell, will oversee the corrective action plan which will be implemented by June 30, 2024.

View Audit 296431 Questioned Costs: $1

Finding 382796 (2023-001)

Significant Deficiency 2023

Hamilton Local School District

OH

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

The district has contracted with the ESC of Central Ohio for an accountant to help with the timely filing of all federal grant requirements. By timely completing project cash requests we will be able to see if variances require changes in the grant budgets. This will minimize correcting entries in t...

The district has contracted with the ESC of Central Ohio for an accountant to help with the timely filing of all federal grant requirements. By timely completing project cash requests we will be able to see if variances require changes in the grant budgets. This will minimize correcting entries in the last week of the fiscal year where mistakes tend to happen in the rush to close the year.

View Audit 296403

Finding 382773 (2023-006)

Material Weakness 2023

Lakeland School Corporation

IN

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.334 § 200.403

FINDING 2023-006 Finding Subject: COVID-19 Education Stabilization Fund – Allowable Costs/Cost Principles Summary of Finding: The School Corporation did not have effective internal controls over the ESSER funds and there was noncompliance in regards to the ESSER funds. Employee pay did not equal wha...

FINDING 2023-006 Finding Subject: COVID-19 Education Stabilization Fund – Allowable Costs/Cost Principles Summary of Finding: The School Corporation did not have effective internal controls over the ESSER funds and there was noncompliance in regards to the ESSER funds. Employee pay did not equal what transferred and supporting documentation for substitute pay and payment of sick days when school was closed. Contact Person Responsible for Corrective Action: Jamesi Lemon and Melanie Summers Contact Phone Number and Email Address: (260) 499-2400; jlemon@lakelandlakers.net/msummers@lakelandlakers.net Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 30 A spreadsheet has been created to track the substitutes and the classes they are covering. Pay scales are also now included in the employee handbooks, so pay can be calculated correctly and tracked. Any transfers of payroll expenses are now completed monthly to ensure the correct amounts are being charged to the ESSER funds. Anticipated Completion Date: Immediately

View Audit 296373

Finding 382749 (2023-001)

Significant Deficiency 2023

Phoenix Houses of Texas, Inc.

TX

Allowable Costs / Cost Principles

Finding #2023-001 – Significant Deficiency. Recommendation: Emphasize adherence to established policies and procedures to ensure payroll, including allocations methodology, are properly followed and reviewed. Planned corrective action: Management has emphasized to HR that adherence to establishe...

Finding #2023-001 – Significant Deficiency. Recommendation: Emphasize adherence to established policies and procedures to ensure payroll, including allocations methodology, are properly followed and reviewed. Planned corrective action: Management has emphasized to HR that adherence to established policies and procedures for reviewing the payroll calculations of the 3rd party payroll vendor must be strictly followed. This finding for shift differential was limited to a very small number of residential treatment employees at one location that worked during overnight hours for 2 pay periods. Changes to shift differential are rare and are not needed in the cost reimbursement business model that took effect on October 1, 2023. In the future, Management will ensure that closer coordination and testing is done with the 3rd party payroll vendor to ensure that all payroll changes are calculated correctly during the correct pay period. Responsible officer: Drew Dutton, President and CEO. Estimated completion date: Completed December 31, 2023

View Audit 296356

Finding 382708 (2023-002)

Material Weakness 2023

Ou Medicine, Inc.

OK

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Period of Performance

Corrective Action Plan Finding 2023-002 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA); Assistance Listing No. 97.036, Disaster Grants – P...

Corrective Action Plan Finding 2023-002 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA); Assistance Listing No. 97.036, Disaster Grants – Public Assistance (Presidentially Declared Disasters) Condition: Per discussion with management, OU Medicine, Inc. has processes and internal controls in place to ensure personnel expenses submitted to the FEMA program were allowable COVID-19-related expenses. These internal controls include ensuring completeness and accuracy of the expenses to ensure the expenses comply with the terms and conditions of the award. However, management did not consistently retain documentation evidencing the performance of these controls. Corrective Action: As part of the Uniform Guidance audit, OU Health provides documentation to explain how eligible costs are/will be identified and submitted. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will develop a checklist to document the review and approval of supporting documentation of costs as reported as federal expenditures. The supporting documentation will be reviewed by management to ensure expenses charged to the federal program are allowable and have not been reimbursed under another federal program. The checklist and all correspondence will be retained with the report and within the Audit Folder. Responsible Official: Bernard Githinji, AVP – Corporate Controller Anticipated Completion Date: April 30, 2024

View Audit 296298

Finding 382707 (2023-003)

Material Weakness 2023

Ou Medicine, Inc.

OK

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Period of Performance

Corrective Action Plan Finding 2023-003 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA); Assistance Listing ...

Corrective Action Plan Finding 2023-003 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA); Assistance Listing No. 93.498, Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions Condition: Per discussion with management, OU Medicine, Inc. has processes and internal controls in place to comply with the terms and conditions of the award and the reporting requirements. However, management did not retain documentation evidencing the performance of these controls. Corrective Action: At the beginning of the pandemic, OU Health created working groups to evaluate the requirements for COVID-19 funding received and ensure the funds were only used for allowable purposes. The working groups were assisted by outside consultants to stay updated on the reporting requirements as the continued to evolve. As part of the Uniform Guidance audit, OU Health provided documentation of the Provider Relief Fund review process that explained how eligible costs were identified and submitted. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will develop a checklist to document the review and approval of supporting documentation of contract labor costs as reported federal expenditures. The supporting documentation will be reviewed by management to ensure expenses charged to the federal program are allowable and have not been reimbursed under another federal program. The checklist will be retained with the existing report. Responsible Official: Bernard Githinji, AVP Corporate Controller Anticipated Completion Date: April 30, 2024

View Audit 296298

Finding 382706 (2023-001)

Material Weakness 2023

Ou Medicine, Inc.

OK

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Period of Performance

Corrective Action Plan Finding 2023-001 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of the Treasury; Assistance Listing No. 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLRF) C...

Corrective Action Plan Finding 2023-001 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of the Treasury; Assistance Listing No. 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLRF) Condition: Per discussion with management, OU Medicine, Inc. has processes and internal controls in place to ensure expenses submitted to the CSLFRF program were allowable expenses per the grant agreement These internal controls include ensuring completeness and accuracy of the expenses to ensure the expenses comply with the terms and conditions of the award. However, management did not consistently retain documentation evidencing the performance of these controls. Corrective Action: As part of the Uniform Guidance audit, OU Health provides documentation to explain how eligible costs are/will be identified and submitted. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will develop a checklist to document the review and approval of supporting documentation of costs as reported as federal expenditures. The supporting documentation will be reviewed by management to ensure expenses charged to the federal program are allowable and have not been reimbursed under another federal program. The checklist and all correspondence will be retained with the report and within the Audit Folder. Responsible Official: Bernard Githinji, AVP – Corporate Controller Anticipated Completion Date: April 30, 2024

View Audit 296298

Finding 382679 (2023-004)

Significant Deficiency 2023

Muncie Community Schools

IN

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

Finding 2023-004 – Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Co...

Finding 2023-004 – Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all payroll amounts recorded to Title I are reviewed to ensure they represent Title I payroll activity only. Anticipated Completion Date: March 2024

View Audit 296252 Questioned Costs: $1

Finding 382635 (2023-003)

Material Weakness 2023

West River Area Health Education Center

SD

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

Finding No. 2023-003: Compliance Controls Responsible Individuals: Stephanie Mayfield, Executive Director Corrective Action Plan: The Organization is continuing to evaluate its internal control systems to ensure proper segregation of duties surrounding various compliance with grant programs. After t...

Finding No. 2023-003: Compliance Controls Responsible Individuals: Stephanie Mayfield, Executive Director Corrective Action Plan: The Organization is continuing to evaluate its internal control systems to ensure proper segregation of duties surrounding various compliance with grant programs. After the Department of Labor review in fiscal year 2024, the Organization implemented new processes and internal controls to improve segregation of duties and address eligibility documentation issues. Anticipated Completion Date: Ongoing

View Audit 296216

Finding 382586 (2023-003)

Significant Deficiency 2023

Portage Township Schools

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

Finding 2023-003 – Special Education Cluster – Earmarking Contact Person Responsible for Corrective Action: Quinnlyn Van Rys Contact Phone Number: 219-850-1914 - qvanrypces.k12.in.us Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Provider/Emp...

Finding 2023-003 – Special Education Cluster – Earmarking Contact Person Responsible for Corrective Action: Quinnlyn Van Rys Contact Phone Number: 219-850-1914 - qvanrypces.k12.in.us Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Provider/Employee will submit payroll records by student services monthly/bi-monthly to the bookkeeper. Once payroll records are received, the CFO will prepare a spreadsheet that calculates the time serviced by the non-public school and member school. Once the total hours are calculated, a percentage based on total hours worked for each member school will be used to allocate the provider/employee time for each member school. This documentation will be attached to each reimbursement request. This documentation will be reviewed and signed off by the Director of Special Education of Portage Township Schools. Anticipated Completion Date: March 2024

View Audit 296149

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