Corrective Action Plans

Finding 403405 (2023-004)

Material Weakness 2023

TX

HUD Housing Programs Allowable Costs / Cost Principles

Corrective Action Plan Finding: 2023-004-Significantly large interfund account needs to be reduced-Allowable Costs/Principles Condition: (a) and (b)-It appears the enrollment, progress of participants to meet the established goals, and potential earning and disbursement of FSS and Set Aside fu...

Corrective Action Plan Finding: 2023-004-Significantly large interfund account needs to be reduced-Allowable Costs/Principles Condition: (a) and (b)-It appears the enrollment, progress of participants to meet the established goals, and potential earning and disbursement of FSS and Set Aside funds have been inadequately monitored for at least the last two years. (c)-Without both of these requested items noted above, we are unable to determine if the SEP contribution terms were adequately complied with. Corrective Action Planned: We will comply with the auditor’s recommendation. I do note that we were short of personnel for the entire audit period. I believe that I have staff presently that can do most of the assigned duties. I admit that not all of the deficiencies noted were due to being understaffed, but lack of training (being new to HUD) and understanding. But we will also correct those errors to the best of our ability. Person responsible for corrective action: Mary Grace Saenz, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2024

View Audit 310515

Finding 403403 (2023-002)

Material Weakness 2023

Anthony Housing Authority

TX

HUD Housing Programs Allowable Costs / Cost Principles Reporting

Corrective Action Plan Finding: 2023-002-Inadequate Administration of Facets of Programs-Allowable Costs/Principles Condition: (a) and (b)-It appears the enrollment, progress of participants to meet the established goals, and potential earning and disbursement of FSS and Set Aside funds have b...

Corrective Action Plan Finding: 2023-002-Inadequate Administration of Facets of Programs-Allowable Costs/Principles Condition: (a) and (b)-It appears the enrollment, progress of participants to meet the established goals, and potential earning and disbursement of FSS and Set Aside funds have been inadequately monitored for at least the last two years. (c)-Without both of these requested items noted above, we are unable to determine if the SEP contribution terms were adequately complied with. Corrective Action Planned: We will comply with the auditor’s recommendation. I do note that we were short of personnel for the entire audit period. I believe that I have staff presently that can do most of the assigned duties. I admit that not all of the deficiencies noted were due to being understaffed, but lack of training (being new to HUD) and understanding. But we will also correct those errors to the best of our ability. Person responsible for corrective action: Mary Grace Saenz, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2024

View Audit 310515

Finding 403402 (2023-001)

Material Weakness 2023

Anthony Housing Authority

TX

HUD Housing Programs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

ANTHONY HOUSING AUTHORITY PHONE: 915-886-4650 ·FAX:915-886-2296 1007 FRANKLIN ANTHONY, TEXAS 79821 HOUSING AUTHORITY OF ANTHONY, TEXAS CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2023 Corrective Action Plan Finding: 2023-001-Inadequate Accounting and Documentation-Allowable Costs/Princip...

ANTHONY HOUSING AUTHORITY PHONE: 915-886-4650 ·FAX:915-886-2296 1007 FRANKLIN ANTHONY, TEXAS 79821 HOUSING AUTHORITY OF ANTHONY, TEXAS CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2023 Corrective Action Plan Finding: 2023-001-Inadequate Accounting and Documentation-Allowable Costs/Principles Condition: (a)-We noted $4,334 of travel costs that were improperly classified in either Maintenance Expense-Materials or Other Administrative Expenses-Other. The above amounts were reclassified by audit adjustment to travel costs. (b)-The adopted policy is for direct payments (ACH- without check) to be accompanied by an authorized check request. As a result of early exceptions we noted, we reviewed approximately 100% of the noted direct payments. Only a minority of the direct payments that we reviewed were accompanied by such an authorized written request. In addition, we do not know the documentation or explanation that was viewed by the authorized person, when the requests that we were able to review was signed. Approximately $55,051 of total payments were made by direct payments. $34,334 and $20,717 were charged to the HCV Fund and the General (Low Rent) Funds, respectively. $49,974 of the total was not supported by adequate documentation. This was $31,586 and $18,388 charged to the HCV and General (Low Rent) Funds, respectively. Much of the unsupported direct payments were travel costs. The total travel costs after reclassifications noted above were $21,336. Of the total travel costs, only $2,723 was paid by check. All tested check amounts contained adequate support. $18,613 of travel costs were paid by direct payments. (c)-We selected three credits at random on the Low Rent rental register that totaled $4,361 that was spread over three months. We requested documented explanations from management for these credits. However, we did not receive any. In addition, we noted in our review of month- to- month Low Rent rental revenue charged, that there was a large variance that may have not been initially detected by management. The average dwelling rent charged for 10 months was $5,800. However, the rent charged for January and February 2023 were $10,855 and $1,570, respectively. We received the accounting information without adjustment or comment on this. Management states that they subsequently found the errors. However, the January variance should have been noted by management before the February rent register was run. (d)-The unaudited financial statements were conditionally approved by REAC. One of the conditions was that PORTs reported on the VMS was $6,009. However, the amount reported on Financial Data Scheule (FDS) Line 97350 is zero. While this difference is immaterial to the financial statements, REAC expects these numbers to agree. To date, management has been unable to reconcile these numbers. (e)-In the current year, Accounting coded a $38,573 advance to a ROSS grant. However, the detailed ELOCCS indicates this is instead was an advance on the CFP 2020 program. In addition, a $46,710 advance was incorrectly classified to the 2021 CFP. Instead, it should have been credited to the 2019 CFP program. (f)-The fee accountant only partially completed their year- end unaudited checklist, that is prepared by a supervising accountant that reviews the year-end unaudited statements prepared by other members of the fee accounting firm. The fee accountant requested but did not receive the necessary information from management. Corrective Action Planned: We will comply with the auditor’s recommendation. I do note that we were short of personnel for the entire audit period. I believe that I have staff presently that can do most of the assigned duties. I admit that not all of the deficiencies noted were due to being understaffed, but lack of training (being new to HUD) and understanding. But we will also correct those errors to the best of our ability. Person responsible for corrective action: Mary Grace Saenz, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2024

View Audit 310515

Finding 403364 (2023-002)

Significant Deficiency 2023

Genesee Health System

MI

Allowable Costs / Cost Principles § 200.402

Finding 2023-002: Activities Allowed or Unallowed and Allowable Cost/Cost Principles Description of Finding: Significant Deficiency in Internal Control/Noncompliance – Expenditures charged to the grant were not authorized in the grant budget. Corrective Action: GHS agrees with the ...

Finding 2023-002: Activities Allowed or Unallowed and Allowable Cost/Cost Principles Description of Finding: Significant Deficiency in Internal Control/Noncompliance – Expenditures charged to the grant were not authorized in the grant budget. Corrective Action: GHS agrees with the finding and the recommendation. GHS grant reporting staff will do a detailed review of all grant agreements to obtain a thorough understanding of allowable costs in the grant budget. Then the following steps will be taken to ensure compliance: • Once the grant budget has been approved by the Board of Directors and submitted to HRSA, staff allocated to the grant will be coded in the payroll system directly to the grant cost center. • Any other costs included in the submitted grant budget will be directly coded to that cost center as incurred on a monthly basis as well. • A review of the costs assigned to the grant cost center will be completed, comparing the actual costs each month to allocated monthly budgeted amount that was approved and submitted to HRSA. • This review will be done by the accounting manager responsible for grant reporting as well as the accounting manager responsible for the FQHC financial reporting as a whole. The Executive Director of the FQHC and the CFO will provide the final review of the monthly expenditures charged to the grant. • Any questions or needed changes will be communicated to the grant accountant for explanation or modification each month. Name of Contact Person: Glen Chipman, CFO 1040 W Bristol Rd Flint, MI 48732 810-496-5487 gchipman@genhs.org Projected Completion Date: The above outlined steps have been put in place as of 6/15/2024 and will be reviewed periodically for continued efficiency.

View Audit 310494

Finding 403363 (2023-001)

Material Weakness 2023

Genesee Health System

MI

Allowable Costs / Cost Principles § 200.402

Finding 2023-001: Activities Allowed or Unallowed and Allowable Cost/Cost Principles Description of Finding: Material Weakness in Internal Control – CMHSP unable to provide supporting documentation for some expenses charged to the grant. Corrective Action: GHS agrees with the findi...

Finding 2023-001: Activities Allowed or Unallowed and Allowable Cost/Cost Principles Description of Finding: Material Weakness in Internal Control – CMHSP unable to provide supporting documentation for some expenses charged to the grant. Corrective Action: GHS agrees with the finding and that there were sufficient costs in other cost centers, allowable by the budget submitted to HRSA, to replace the unsupported expenses. We also acknowledge the fact that the controls in place were not effectively applied to identify the issue prior to the single audit testing began. GHS has already taken steps to eliminate the risk of such an issue in the future by automating the coding process through the payroll system and increasing the number of reviewers of grant related expenditures on a monthly basis. The following steps have been put in place for future years: • Once the grant budget has been approved by the Board of Directors and submitted to HRSA, staff allocated to the grant will be coded in the payroll system directly to the grant cost center. • Any other costs included in the submitted grant budget will be directly coded to that cost center as incurred on a monthly basis as well. • A review of the costs assigned to the grant cost center will be completed, comparing the actual costs each month to allocated monthly budgeted amount that was approved and submitted to HRSA. • This review will be done by the accounting manager responsible for grant reporting as well as the accounting manager responsible for the FQHC financial reporting as a whole. The Executive Director of the FQHC and the CFO will provide the final review of the monthly expenditures charged to the grant. • Any questions or needed changes will be communicated to the grant accountant for explanation or modification each month. Name of Contact Person: Glen Chipman, CFO 1040 W Bristol Rd Flint, MI 48732 810-496-5487 gchipman@genhs.org Projected Completion Date: The above outlined steps have been put in place as of 6/15/2024 and will be reviewed periodically for continued compliance.

View Audit 310494

Finding 403357 (2023-005)

Material Weakness 2023

Mile Bluff Medical Center, Inc.

WI

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified the lack of documentation of review processes surrounding the expenditures ...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified the lack of documentation of review processes surrounding the expenditures of the federal award. Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: We have a process that requires the Grant “owners” to review and sign off on the expenditures related to any Federal Awards and other expenditure in the organization. We will add a quarterly review in the Grants office to verify the expected purpose, compliance with federal statutes, regulations and conditions of the federal award. This will also be reviewed by the CFO to create checks and balances. Anticipated Completion Date: Ongoing

View Audit 310474

Finding 403350 (2023-033)

Significant Deficiency 2023

Government of the District of Columbia

DC

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

The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of requests for reimbursement for all federal grants prior to submitting the request in the federal system. The accountant will be required to su...

The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of requests for reimbursement for all federal grants prior to submitting the request in the federal system. The accountant will be required to submit supporting documentation reflecting the summary and detailed personal and non-personal service expenditures. Contact - Adran Reid, DBH Agency Fiscal Officer Estimated Completion Date - July 1, 2024 See Corrective Action Plan for chart/table

View Audit 310468 Questioned Costs: $1

Finding 403340 (2023-031)

Significant Deficiency 2023

Government of the District of Columbia

DC

Allowable Costs / Cost Principles Period of Performance Reporting § 200.303

The Department of Health Care Finance (DHCF) agrees with the finding. The drug rebate vendor’s IT staff will test the calculation to see if there would have been interest calculated or if there is a system glitch that requires further attention. If additional interest should be billed for this invo...

The Department of Health Care Finance (DHCF) agrees with the finding. The drug rebate vendor’s IT staff will test the calculation to see if there would have been interest calculated or if there is a system glitch that requires further attention. If additional interest should be billed for this invoice, the vendor will add the interest that should have been billed. Currently, the drug rebate vendor calculates interest every Tuesday. The system is also calibrated to calculate interest on invoices that were paid in full that had outstanding balances based on the postmark date applied in the system. Contact - Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - November 30, 2024 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403336 (2023-027)

Significant Deficiency 2023

Government of the District of Columbia

DC

Allowable Costs / Cost Principles § 200.303

The Child and Family Services Agency (CFSA) concurs with the finding. The issues related to pre-approval of overtime for the three employees in question pertained to pay periods that pre-dated CFSA’s corrective action on this same issue that resulted from the fiscal year 2022 Single Audit. Correct...

The Child and Family Services Agency (CFSA) concurs with the finding. The issues related to pre-approval of overtime for the three employees in question pertained to pay periods that pre-dated CFSA’s corrective action on this same issue that resulted from the fiscal year 2022 Single Audit. Corrective action on this issue, therefore, has already been taken. Regarding supervisory social worker validation of RMS responses, by September 30, 2024, the Business Services Administration will schedule supervisor trainings regarding the validation process and will publish performance statistics to the clinical management team to enhance validation response rates and accountability. Contact - James J. Murphy, Director, Business Services Administration Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403331 (2023-022)

Material Weakness 2023

Government of the District of Columbia

DC

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Department of Human Services (DHS) agrees with the findings. Economic Security Administration (ESA) agrees with the documentation issue, which is compounded by the lack of interface between the reporting data systems. This requires collaboration efforts between multiple units within ESA that in...

The Department of Human Services (DHS) agrees with the findings. Economic Security Administration (ESA) agrees with the documentation issue, which is compounded by the lack of interface between the reporting data systems. This requires collaboration efforts between multiple units within ESA that includes the Division of Customer Workforce Employment & Training (DCWET), the Department of Program Operations (DPO), and the Division of Innovation and Change Management (DICM). ESA needs to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. The Office of Performance Monitoring (OPM) has a process in place to monitor and confirm the hours reported from CATCH; however, the process to monitor and verify the hours received from DCAS needs to be strengthened to capture and resolve discrepancies in work hours. During the monthly Q5I reviews, we found multiple discrepancies from the data received from DCAS showing that the customer was not employed during the sample month or fiscal year; but hours were reported in Q5i. When OPM conducts their review of DCAS hours, and identifies income and hour differences, the DPO is informed and/or the Office of Work Opportunity (OWO) requests their assistance with resolving the discrepancy. While this was a temporary fix for the problem, however, a permanent solution would require a multi-faceted approach: (1) Training (re-training) all DPO SSR on the DCAS screens which require action to confirm employment. This means that the DPO should dedicate resources to provide adequate training to SSRs involved in updating customers’ employment information in DCAS. While this would be a short-term solution it will go a long way to resolving some of the discrepancies in reported work hours that are being transmitted to Q5i. (2) Requiring DICM to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. Her suggestion is to have Brian initiate the meetings between DCWET, DPO, and DICM. This would be automating the process by connecting the 2- step process into one task. This would be a permanent solution to curbing stale and unsubstantiated hours from migrating to Q5i. (3) Continuing to randomly select and review a sample of 40 cases from Q5i each month. OPM monitors will randomly generate 40 sample cases from Q5i, review them and if they find any discrepancies would refer them to either OWO, DPO, or TEP Providers for resolution. (4) Continuing to cross-reference all customers assigned to a vendor to verify that each customer’s DCAS hours are confirmed by OPM during its participation audit process. OPM will continue to ensure that all customers’ participation documents are uploaded in Fileshare during each bi-weekly audit cycle. Contact - Christian Okonkwo, Program Manager, Office of Performance Monitoring, DHS/ESA Estimated Completion Date - DICM will create a Jira ticket to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. This process will take four (4) months, September 30, 2024, to complete. DPO will train (retrain) all DPO SSR on the DCAS screens which require action to confirm employment. The training will last up to six (6) months, March 30, 2025. See Corrective Action Plan for chart/table

View Audit 310468

Finding 403328 (2023-019)

Significant Deficiency 2023

Government of the District of Columbia

DC

Allowable Costs / Cost Principles § 200.303 § 200.430

The Department of Human Services (DHS) concurs with the finding. DHS will comply with current District Personnel Issuance No. 2021-07 which requires that overtime must be officially ordered and approved in advance. Agency heads and their designees are authorized to order and approve overtime worked...

The Department of Human Services (DHS) concurs with the finding. DHS will comply with current District Personnel Issuance No. 2021-07 which requires that overtime must be officially ordered and approved in advance. Agency heads and their designees are authorized to order and approve overtime worked provided the agency has sufficient funding available. DHS will ensure that the appropriate agency designees both authorized and approve overtime in writing in advance of a Department/Unit working overtime hours. DHS employees will not be required to submit a form in advance of working overtime consistent with current District policies. Additionally, DHS will ensure that managers memorialize leave requests in writing in a manner that is best suited for the operational needs of the Department/Unit. Contact - Tania Mortensen, Chief Operating Officer, Marlene Akas, Human Resources Officer Estimated Completion Date - July 1, 2024 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403317 (2023-014)

Significant Deficiency 2023

Government of the District of Columbia

DC

Allowable Costs / Cost Principles § 200.303 § 200.430

The Department of Behavioral Health (DBH) and Department of Energy and Environment (DOEE) concur with the findings. DBH will perform monthly review of personnel services expenditures and reclass unallowable cost when applicable. DOEE will set biweekly reminder to employees to keep combo code field...

The Department of Behavioral Health (DBH) and Department of Energy and Environment (DOEE) concur with the findings. DBH will perform monthly review of personnel services expenditures and reclass unallowable cost when applicable. DOEE will set biweekly reminder to employees to keep combo code field blank for various leave time reporting codes. Also, the agency will request OPRS to produce monthly TRC report for further review by DOEE managers approving time. Contact - Adran Reid, Agency Fiscal Officer, Lauren Maxwell, HR Director; and Tiehdi Johnson, Financial Manager Estimated Completion Date - September 30, 2024, Expecting time reporting codes (TRC) report by the end of July 31, 2024 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403304 (2023-006)

Significant Deficiency 2023

Government of the District of Columbia

DC

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

The District Department of Health (DC Health) concurs with the finding. Policy and Procedure: DC WIC will draft an internal policy and procedure as part of the program’s statewide Policy and Procedure manual, outlining the standard operating process to review and approve annual rebates from a vendo...

The District Department of Health (DC Health) concurs with the finding. Policy and Procedure: DC WIC will draft an internal policy and procedure as part of the program’s statewide Policy and Procedure manual, outlining the standard operating process to review and approve annual rebates from a vendor. DC WIC will train key staff at DC Health including program and financial staff on the new policy and procedure. Supporting Documentation: DC Health and a service provider have agreed via email to the following annual process. 1) The service provider emails cover letter to DC WIC contacts to review rebate dollar amount and direct deposit account number. 2) DC WIC replies confirming or correcting information provided. 3) The service provider deposits annual rebate into DC Health account. Contact - Sara Beckwith, Bureau Chief, Nutrition and Physical Fitness Bureau Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403303 (2023-005)

Significant Deficiency 2023

Government of the District of Columbia

DC

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

The District Department of Health (DC Health) concurs with the finding. As part of the system of internal controls, the Deputy Director for Operations (DDO), manager and supervisor will review the 485 and position funding reports on a quarterly basis. This will ensure that an employee’s time is rec...

The District Department of Health (DC Health) concurs with the finding. As part of the system of internal controls, the Deputy Director for Operations (DDO), manager and supervisor will review the 485 and position funding reports on a quarterly basis. This will ensure that an employee’s time is recorded and documented per the funding source and will allow for the correction of any variance between what was budgeted, and the actual time worked. The DDO will sign off on the supervisors’ time and effort certifications that find an exception in paid time to budget and actual time worked. DC Health will also increase management training on the review of employee assignments and changes in those assignments to allowable costs. We will revise the section of the SOP 430 (Time and Effort Certification) to increase the frequency of 485 review. Contact - Clara Ann McLaughlin, Chief – Office of Grants Management Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

View Audit 310468 Questioned Costs: $1

Finding 403291 (2023-001)

Significant Deficiency 2023

Government of the District of Columbia

DC

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

The Department of Human Services (DHS) concurs with the finding. DHS will ensure that managers memorialize leave and overtime requests in writing in a manner that is best suited for the operational needs of the Department/Unit. Contact - Tania Mortensen, Chief Operating Officer, Marlene Akas, Huma...

The Department of Human Services (DHS) concurs with the finding. DHS will ensure that managers memorialize leave and overtime requests in writing in a manner that is best suited for the operational needs of the Department/Unit. Contact - Tania Mortensen, Chief Operating Officer, Marlene Akas, Human Resources Officer Estimated Completion Date - July 1, 2024 See Corrective Action Plan for chart/table

View Audit 310468 Questioned Costs: $1

Finding 403270 (2023-001)

None 2023

Pentucket Regional School District

MA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The Pentucket Regional School District respectfully submits the Following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, sch...

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The Pentucket Regional School District respectfully submits the Following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. DEPARTMENT OF EDUCATION Passed through Massachusetts Department of Elementary and Secondary Education Special Education Cluster Special Education Grants to States Federal Assistance Listing No. 84.027 Special Education Preschool Grants Federal Assistance Listing No. 84.173 2023-001: Controls for Monitoring Payroll Charged to the Grant Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Compliance and Internal Control Over Compliance – Other Matter Criteria or Specific Requirement: Grantees must provide reasonable assurance that Federal Awards are expended only for allowable activities and that the costs of goods and services charged to Federal awards are allowable and in accordance with applicable cost principles. Condition: Payroll expenditures charged to the Special Education Cluster grant are required to be supported with documentation (i.e., semi-annual certifications and personnel activity reports) substantiating that the employees are eligible to be charged to the grant and that the payroll charged relates to time spent accomplishing grant objectives. The District does not utilize semi-annual time and effort certification forms to document the eligibility of the employees paid out of the grant. Context: The District did not maintain sufficient documentation to demonstrate compliance with federal and state time and effort reporting requirements in accordance with the provisions of Title 2 U.S. Code of Federal Regulations Part 225 Cost Principals for State, Local, and Indian Tribal Governments. Effect: The District has not complied with the federal and state time and effort reporting requirements. Cause: Management has established written guidelines and procedures outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. The written guidelines and procedures outlined by management are not being followed as designed. Questioned Costs: Total payroll costs charged to the grant in 2023 totaled $703,789, which was paid on a bi-weekly basis throughout the year. Three of the pay periods were selected for testing, which totaled $117,345 for 61 employees paid out of the grant during those pay periods. From the pay periods selected for testing, the following known questioned costs were identified: Recommendation: The District should follow their written policies and procedures outlining the time and effort reporting and documentation requirements that must be adhered with to ensure compliance with federal and state time and effort reporting requirements. Management should adopt and implement standardized forms that include all data required by federal and state guidelines and provide training to ensure that program personnel understand the time and effort reporting requirements. Views of Responsible Officials and Planned Corrective Actions: The School District immediately began designing the form used for time and effort reporting related to special education grants, and the School District will begin issuing and collecting the forms for the special education grant for 2024, and future periods. If the Oversight Agency has questions regarding this plan, please call Suzanne Wallace, School Business Manager, at 978-346-7424, extension 126. Sincerely yours, Suzanne Wallace School Business Manager Pentucket Regional School District

View Audit 310445 Questioned Costs: $1

Finding 403233 (2023-005)

Significant Deficiency 2023

Chief Dull Knife College

MT

Allowable Costs / Cost Principles

Allowability of Expenditures: Chief Dull Knife College has reviewed and updated the policies for expenditures and will continue to review, scrutinize and calculate all expenditure requests to eliminate any expenditures being paid without proper support or inaccurately added totals. All departments ...

Allowability of Expenditures: Chief Dull Knife College has reviewed and updated the policies for expenditures and will continue to review, scrutinize and calculate all expenditure requests to eliminate any expenditures being paid without proper support or inaccurately added totals. All departments have been made aware of the policies and procedures.

View Audit 310397

Finding 403212 (2023-001)

Material Weakness 2023

Houston County Board of Education

AL

Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions § 200.303 § 200.326

Item 2023‐001 – Special Tests and Provisions – Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non‐Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non‐Federal entity is managing the Federa...

Item 2023‐001 – Special Tests and Provisions – Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non‐Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.” 2 CFR 200.326 and 29 CFR Part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction (DOL Regulations) require the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls). We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. The Chief School Financial Officer, Kerry Bedsole, should review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She should also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed. Action Taken: Management has reviewed the requirements of 2 CFR Section 200.303 and 2 CFR 200.326 relating to wage rate requirements and agrees with the recommendation. Management has already communicated with all contractors and subcontractors regarding the wage rate requirements and has implemented additional procedures, effective October 1, 2023, stating that the Chief School Financial Officer, Kerry Bedsole, will review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She will also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed.

View Audit 310378 Questioned Costs: $1

Finding 403177 (2023-101)

None 2023

Valley Health Systems, Inc.

MA

Allowable Costs / Cost Principles Cash Management

Unallowable Costs Criteria: The Organization must submit only allowable costs for reimbursement under the accounting principles contained in Uniform Guidance. Condition: During compliance testing, it was noted that one out of twenty five selections improperly included alcohol in the balances submit...

Unallowable Costs Criteria: The Organization must submit only allowable costs for reimbursement under the accounting principles contained in Uniform Guidance. Condition: During compliance testing, it was noted that one out of twenty five selections improperly included alcohol in the balances submitted for expense reimbursements. Context: One expense reimbursement was found to have reimbursed alcohol. Cause: There was a lack of consistent review of the receipt before submission for expense reimbursement. Effect: As a result of the condition, one reimbursement was overpaid. Recommendation: In the future, the Organization should review reimbursements closely to ensure unallowable costs are not submitted for reimbursement. Contact: Erin Spaulding, Senior Director of Finance. Corrective Actions Taken or Planned: Management acknowledges the finding and will take action to ensure that no unallowable costs are being reimbursed.

View Audit 310342

Finding 403169 (2023-002)

Significant Deficiency 2023

Freeborn County

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management

Timestudy Testing Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audi...

Timestudy Testing Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2024

View Audit 310310

Finding 403144 (2023-002)

Significant Deficiency 2023

United Tribes Technical College

ND

Allowable Costs / Cost Principles

The FY23 and FY24 Indirect Costs Proposals were submitted and approved in January 2024. The College adjusted the IDC collections for FY23 and is currently using the FY24 IDC approved rate. The College continues to use an outside entity to work with UTTC Finance staff to complete future IDC Proposals...

The FY23 and FY24 Indirect Costs Proposals were submitted and approved in January 2024. The College adjusted the IDC collections for FY23 and is currently using the FY24 IDC approved rate. The College continues to use an outside entity to work with UTTC Finance staff to complete future IDC Proposals in a timely manner. We expect the FY 25 and FY26 IDC Proposal to be submitted by December 31, 2024. The CFO is responsible to ensure this is completed.

View Audit 310273

Finding 403100 (2023-002)

Material Weakness 2023

Casa Grande Union High School District No. 82

AZ

Questioned Costs Allowable Costs / Cost Principles § 200.303

Finding Number: 2023‐002 Assistance Listing Numbers: 84.010; 84.027; 84.027X; 84.425U Program Names/Assistance Listing Titles: Title I Grants to Local Educational Agencies; Special Education Cluster; COVID‐19 Education Stabilization Fund Contact Person: Glenda Cole, Human Resources Director An...

Finding Number: 2023‐002 Assistance Listing Numbers: 84.010; 84.027; 84.027X; 84.425U Program Names/Assistance Listing Titles: Title I Grants to Local Educational Agencies; Special Education Cluster; COVID‐19 Education Stabilization Fund Contact Person: Glenda Cole, Human Resources Director Anticipated Completion Date: May 30, 2025 Planned Corrective Action: It has been noted that several of the concerns associated with lack of appropriate payroll procedures occurred due to lack of clear communication with HR regarding rates of pay for new and continuing employees. Therefore, procedures have been put in place to address these issues to ensure an effective, transparent process. The following procedures are in place (or are being implemented) to improve performance in the HR/Payroll Department: I. Position Changes for Employees During the School Year: Position Changes for an employee during the school year will be addressed in the following manner: a. The governing board will continue to receive a personnel recommendation form that includes: i. Employee name ii. Position details (such as rate of pay, position title, control code‐if the position is a replacement.) iii. Site relocation (if applicable) iv. Reason for the position change v. Effective date of the change b. Agreements/Contracts will be issued to staff members for their signature. c. Payroll receives the personnel document after board approval. If the position change for the employee is a replacement, payroll uses the control assigned by HR. If the position change is a new position, Finance assigns the control code and sends to HR. II. Agreements/Contracts for Staff Members: a. Agreements/contracts will be created for each staff member to obtain staff member signature after board approval. b. Agreements will be placed in the staff members’ files. c. Agreements will include: i. Employee name ii. New position/title iii. Site relocation (if applicable), iv. Rate of pay v. Effective date. vi. Employee signature and date d. Tracking of these agreements will occur using onboarding and transfer agreement spreadsheets. III. Communications a. Payroll and HR staff will meet weekly to clarify hiring/payroll issues as they arise. b. A documented flow of information; forms initiated by HR will be shared with payroll to ensure clarity of intent. IV. Flexibility and Amendments: a. As the process continues, certain points will be amended or adjusted to improve the efficiency of tracking employee status changes. V. Training a. HR and Payroll Staff received training last year regarding the use of HR and payroll software and will receive updated training in the 2024‐2025 school year. The District will reimplement (it had been used prior to 2022, but was discontinued) a more thorough use of payroll software in spring of 2025 to increase efficiency and accuracy. b. We will hire a consultant to work with staff for the 2024‐25 school year to ensure more transparent and efficient practice of tracking employee status changes in the District.

View Audit 310236 Questioned Costs: $1

Finding 403098 (2023-001)

Significant Deficiency 2023

Casa Grande Union High School District No. 82

AZ

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Contact Person: Christina Ogle, Federal & State Programs Director Anticipated Completion Date: May 30, 2025 Planned Corrective Action: A Use of Funds by Category reporting documen...

Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Contact Person: Christina Ogle, Federal & State Programs Director Anticipated Completion Date: May 30, 2025 Planned Corrective Action: A Use of Funds by Category reporting document has been developed to support Part 1 of the LEA Uses of ESSER funds reporting requirements. Additionally, maintaining an ESSER Reporting documentation spreadsheet. The ESSER reporting spreadsheet includes PO#’s and JE’s with expenditures that are in alignment with the ESSER Use of Funds reporting. These documents and spreadsheets are compiled by utilizing: - Transaction Detail Reports – Visions - Purchase Order Pay History Report – Visions - Payroll Distribution Reports – Visions - ESSER Budget – Grants Management Enterprise These documents/spreadsheets are also shared with the Federal & State Programs Coordinator and will be uploaded into GME related documents for continuity regardless of staffing changes.

View Audit 310236

Finding 403064 (2023-006)

Significant Deficiency 2023

Resilience: Advocates for Ending Violence

MI

Allowable Costs / Cost Principles Cash Management Internal Control / Segregation of Duties

Finding 2023-006: Crime Victim Assistance Documented Review and Approval Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: Septemb...

Finding 2023-006: Crime Victim Assistance Documented Review and Approval Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: September 30, 2023 Recommendation: The Organization should establish procedures to require the documented review and approval of all indirect cost calculations, cash management requests for funds, and reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Organization will establish the necessary policies and procedures to require the documented review and approval of all indirect calculations, cash management requests for funds and performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2024.

View Audit 310209

Finding 403063 (2023-005)

Material Weakness 2023

Resilience: Advocates for Ending Violence

MI

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

Finding 2023-005: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: Sep...

Finding 2023-005: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: September 30, 2023 Recommendation: The Organization should establish procedures to require the documented review and approval of all indirect cost calculations, cash management requests for funds, and reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Organization will establish the necessary policies and procedures for managing its federal awards in compliance with federal requirements. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2024.

View Audit 310209

Corrective Action Plans

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