Corrective Action Plans

Finding 395990 (2023-002)

Material Weakness 2023

Boys and Girls Clubs of Philadelphia, Inc.

PA

Questioned Costs Allowable Costs / Cost Principles Cash Management

The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/27/22 to 7/8/22, with a pay date of 7/15/22). Reports to the funder for the year ending 6/30/22 were due on 7/10/22, before all payroll information and supporting documentation for this pay perio...

The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/27/22 to 7/8/22, with a pay date of 7/15/22). Reports to the funder for the year ending 6/30/22 were due on 7/10/22, before all payroll information and supporting documentation for this pay period was available. Therefore, the full pay period was included in the July reimbursement report. This practice was approved by the funder. Moving forward, the organization will be more cognizant of accrual dates for payroll reporting and submit a true-up as needed to ensure that payroll costs are correctly allocated at the end of the fiscal year. Additionally, in May 2024, the organization will be implementing a new electronic payroll system that will allow us to obtain this information more quickly at the close of each fiscal year to complete billing reports.

View Audit 305611 Questioned Costs: $1

Finding 395985 (2023-002)

Significant Deficiency 2023

Rfe/rl, Inc.

DC

Reporting Allowable Costs / Cost Principles § 200.301

Views of Responsible Officials: Management acknowledges the importance of timely reporting. RFE/RL is committed to improving timeliness by engaging an outside accounting firm to bring the company into compliance with current reporting requirements, increasing staff capacity, implementing a new repor...

Views of Responsible Officials: Management acknowledges the importance of timely reporting. RFE/RL is committed to improving timeliness by engaging an outside accounting firm to bring the company into compliance with current reporting requirements, increasing staff capacity, implementing a new reporting software tool, documenting sustainable reporting procedures and working with our funder on agreed upon reports and deadlines.

View Audit 305606

Finding 395832 (2023-005)

Significant Deficiency 2023

Bertie County

NC

Allowable Costs / Cost Principles Reporting Cash Management

Finding: 2023‐005: Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Daphine Little, Director of Bertie County Department of Social Services Corrective Action/Management's Response: DSS agrees that there were some discrepanc...

Finding: 2023‐005: Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Daphine Little, Director of Bertie County Department of Social Services Corrective Action/Management's Response: DSS agrees that there were some discrepancies found in two out of twenty‐three employee daysheets vs. timesheets resulting in more program time reported on the daysheets than the approved timesheets. Supervisors are responsible for ensuring that time reported on employee daysheets matches the timesheets. Bertie County DSS utilizes an Excel spreadsheet provided by Bertie County Government that is completed by each employee monthly to report time worked. As it is the Supervisor’s responsibility to verify and approve the accuracy of employee daysheets, the Supervisor is expected to reconcile time reported on employee daysheets to time reported on employee timesheets. Plan of Action:  Provide employees with a copy of Power Point Training ‐Day Sheets: Time Reporting and Reimbursement for County DSS (2022).  Reiterate the importance of employees reporting the same amount of time on the daysheet vs. the timesheet.  Communicate with Supervisors the importance of reconciling employee daysheets vs. timesheets. Proposed Completion Date: March 1, 2024

View Audit 305469

Finding 395816 (2023-103)

Material Weakness 2023

Greater Phoenix Urban League INC

AZ

Allowable Costs / Cost Principles Cash Management Material Weakness

Finding 2023-103 Allowable Costs/Cost Principles/Reporting (Material Weakness, Compliance Finding) Repeat Finding. Responsible Individuals: William Bridgeman, Chief Fiscal Officer Natalie Alvarez, Chief Operating Officer- Head Start Director Corrective Action Plan: Greater Phoenix Urban League (Dele...

Finding 2023-103 Allowable Costs/Cost Principles/Reporting (Material Weakness, Compliance Finding) Repeat Finding. Responsible Individuals: William Bridgeman, Chief Fiscal Officer Natalie Alvarez, Chief Operating Officer- Head Start Director Corrective Action Plan: Greater Phoenix Urban League (Delegate Agency) will continue its on- going collaborate with the City of Phoenix (Grantee) in evaluating the process and effectiveness of inserting and updating the “quarterly administrative reporting package”, relatively to its use and the accuracy of the content that flows within the excel workbooks. Anticipated Completion Date: On going throughout the contract period on an annualized basis. July 1, 2024

View Audit 305459

Finding 395815 (2023-102)

Material Weakness 2023

Greater Phoenix Urban League INC

AZ

Questioned Costs Allowable Costs / Cost Principles Reporting

Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by...

Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by individual general ledger. Each revenue and expenses account are supported with documentation. Classes within QuickBooks are available within the platform. However, using classes is optional and with the purchase of the more advance version of QuickBooks “QuickBooks Enterprise Platinum” it’s the intent of the organization to move to enhanced detail general ledger accounts (which will provide detail data relating to each individual transaction). As it relates to Assistance Listing No 93.185 National Urban League Vaccine Equity 2021-22 in the amount of $40,000 and Assistance Listing no. 10-551 in the amount of $52,129 is not affiliated with Head Start from a program perspective. No staff time or expenses of the two grants are related to the Head Start Program. Each of the reference programs are stand-alone funded through a third-party pass through grantee and not a direct grant from a federal agency. However, the organization will establish separate classes within QuickBooks Enterprise Platinum for each federal and state contract. The implementation of the vertical classes within the QuickBooks Enterprise Platinum platform will consist of the reconciliation of cost reimbursements with a separate and dedicated “in kind” calculation of 25% within the class where applicable as per grantee requirement. Implementation Date: July 1, 2024

View Audit 305459 Questioned Costs: $1

Finding 395814 (2023-101)

Material Weakness 2023

Greater Phoenix Urban League INC

AZ

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2023-101 Allowable Costs/Cost Principle and Reporting (Material Weakness Compliance Finding) Repeat Finding Responsible Individuals: William Bridgeman Chief Fiscal Officer Natalie Alvarez- Chief Operating Officer Head Start Director Corrective Action Plan: Greater Phoenix Urban League has r...

Finding 2023-101 Allowable Costs/Cost Principle and Reporting (Material Weakness Compliance Finding) Repeat Finding Responsible Individuals: William Bridgeman Chief Fiscal Officer Natalie Alvarez- Chief Operating Officer Head Start Director Corrective Action Plan: Greater Phoenix Urban League has received great support from our community partners by providing in-kind space in 4 school districts and the abundance of parent volunteer support for our Head Start program, however, the program struggles to identify the in-kind match during the turn to full on campus instruction. COVID19 has had a considerable impact on the programs ’s ability to meet the non-federal share obligation as families and community volunteers are not allowed fully back onto Head Start Campuses and enrollment has declined. The program was unable to open several classrooms due to lack of qualified staff and low enrollment. In the past, Greater Phoenix Urban League Head Start has relied heavily on in-kind Space as the main source of program match and with the closing of classrooms in-kind was very difficult to collect. We believe we have worked towards meeting the challenge of program in-kind match. We have used ARPA funds to develop “A grow your own program.” Greater Phoenix Urban League Head Start has recruited parents and the community to participant in a workforce development program to train and hire new Head Start staff as classroom aides and teacher assistances. We also have contracted with an organization to provided contracted instructional support to open up temporarily closed classrooms. The program will continue to identify non-federal share to meet the obligations of the grant award. COVID will continue to have an impact on the programs ’s ability to meet non-federal share but it certainly opens new channels of identifying non-federal share. The following steps are in progress of being implemented in fiscal year 23-24 within the grantee: • An internal control process has been developed to review the current system to document the resources for non-federal share. A Data Assistant will review and analyze at our process in collecting in kind. • Revised Policies and procedures will be developed to assisted instructional staff to collect parent volunteer hours. • Parent Policy Committee will be trained on the non-federal share in-kind as it relates to their important role within the Head Start Program. • Greater Phoenix Urban League Head Start will continue to review the internal control process annually to ensure compliance with the Head Start Program Performance Standards, federal regulations, and City of Phoenix Grantee regulations. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • Greater Phoenix Urban League will continue their efforts to identify citywide partners that can provide non-federal share to the Head Start Program. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • All third-party appraisals will be conducted in May 2024 to reflect the current market value of space and real property. • The activities mentioned above will assist the Greater Phoenix Urban League-Head Start Program in meeting its obligations in the coming years. Anticipated Completion Date: Ongoing throughout the contract period on an annualized basis. May 1, 2024

View Audit 305459 Questioned Costs: $1

Finding 395809 (2023-001)

None 2023

Health Department of Northwest Michigan

MI

Allowable Costs / Cost Principles

Accounting leadership will review general Federal guidelines for allowable costs with directors and supervisors. Additionally, directors and supervisors will be reminded of their responsibility for, and the importance of, carefully reviewing coding of individual program expenditures to align with Fe...

Accounting leadership will review general Federal guidelines for allowable costs with directors and supervisors. Additionally, directors and supervisors will be reminded of their responsibility for, and the importance of, carefully reviewing coding of individual program expenditures to align with Federal guidelines. Accountants currently meet monthly with directors and supervisors to review the financial status of each program, including unreasonable budget variances and the reasonableness of current expenditure levels. Going forward, they will also review the individual expenditures in categories deemed most likely to have unallowable transactions

View Audit 305437

Finding 395759 (2023-004)

Significant Deficiency 2023

Grand Forks Regional Airport Authority

ND

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

Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures over payment requests to ensure allowability accuracy. Completion Date –December 31, 2024

View Audit 305388 Questioned Costs: $1

Finding 395755 (2023-002)

Significant Deficiency 2023

Occk, Inc.

KS

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Auditors’ Recommendation: We recommend the Agency implement control activities and monitoring procedures to ensure monthly reports that are submitted to the funding agencies are accurately reflecting allowable grant costs. Action Taken: We agree with the finding and have taken the actions as outlin...

Auditors’ Recommendation: We recommend the Agency implement control activities and monitoring procedures to ensure monthly reports that are submitted to the funding agencies are accurately reflecting allowable grant costs. Action Taken: We agree with the finding and have taken the actions as outlined in finding 2023‐001 to fully address and improve the control process. Specifically, Agency management has reviewed the internal processes and enhanced control activities to ensure the mechanic salaries are accurately reported in the monthly operating reports going forward.

View Audit 305387 Questioned Costs: $1

Finding 395754 (2023-001)

Significant Deficiency 2023

Occk, Inc.

KS

Questioned Costs Allowable Costs / Cost Principles

Auditors’ Recommendation: Agency management took immediate action to determine the effect for the entire year, communicated with the auditor, communicated with the Kansas Department of Transportation, and developed the plan to respond to the finding. As recommended by the Kansas Department of Transp...

Auditors’ Recommendation: Agency management took immediate action to determine the effect for the entire year, communicated with the auditor, communicated with the Kansas Department of Transportation, and developed the plan to respond to the finding. As recommended by the Kansas Department of Transportation, a check for $13,715 will be written to the Kansas Department of Transportation. The last six‐month amount of $20,781 will be reported on the February, 2024, operating report to reduce the Kansas Department of Transportation reimbursement provided to the Agency for the year ending June 30, 2024. Action Taken: We agree with the finding and have taken the following actions to fully address and correct the discrepancies. 1. Agency management reviewed all twelve months of 2023 billing to determine the total amount to return to the Kansas Department of Transportation. After this review, management determined that the overreporting discrepancies began in January, 2023, and occurred every month through December, 2023. 2. A meeting was held between Agency management and the Kansas Department of Transportation Program Administrator and Program Consultant to discuss the findings and determine a plan of action to correct the discrepancies. The action planned is outlined in the Recommendation section of this finding. 3. Monthly Operating Budget billings for January 2023 through December 2023, were reviewed and the appropriate amounts that should have been billed were determined and compared to the actual amount billed to KDOT. The net result is as identified in the Recommendation section of this finding. 4. Agency management has reviewed the internal processes and enhanced control activities to ensure the mechanic salaries are accurately reported in the monthly operating reports going forward.

View Audit 305387 Questioned Costs: $1

Finding 395744 (2023-003)

Material Weakness 2023

Ucan

IL

Allowable Costs / Cost Principles § 200.405

Identifying Number: 2023-003 Finding: Allowable Costs Corrective Action Taken or Planned: Procedures have been updated to include procedures and internal controls for regular review of the general ledger of their programs and reconcile to the vouchers prior to submission to the granting agency. Anti...

Identifying Number: 2023-003 Finding: Allowable Costs Corrective Action Taken or Planned: Procedures have been updated to include procedures and internal controls for regular review of the general ledger of their programs and reconcile to the vouchers prior to submission to the granting agency. Anticipated Implementation and Responsible Official: April 30, 2024, Suresh Sharma, Chief Financial Officer

View Audit 305385

Finding 395731 (2023-001)

Significant Deficiency 2023

Disability Rights Maine

ME

Allowable Costs / Cost Principles

Corrective Action Plan for Current Year Finding 2023-001 – Internal Control over Allocation of Payroll Description of Finding: The allocation of payroll between grants was inaccurate due to errors when restoring the allocation workbook used to calculate payroll as well as an employee changing progra...

Corrective Action Plan for Current Year Finding 2023-001 – Internal Control over Allocation of Payroll Description of Finding: The allocation of payroll between grants was inaccurate due to errors when restoring the allocation workbook used to calculate payroll as well as an employee changing programs and new position filled which were not reflected properly in the allocation. Cause: Insufficient internal controls due to inadequate staffing. Effect: Without ensuring the payroll allocation is proper based on time and effort records as well as predetermined program allocations, it is possible that grants could be overcharged, resulting in misstated financial statements and unallowable costs. Corrective Action: DRM is committed to adequate staffing levels. Executive Management realizes the necessity for adequate staffing levels to maintain top notch internal controls. The following corrective actions will be taken to avoid the misallocation of payroll funds moving forward. 1. All program allocation updates in the payroll workbook will be completed by the CFO. 2. Any malfunctions in the payroll workbook will be reported to the CFO by the payroll processor before the Labor Distribution Report (LDR) is imported for time distribution. 3. The CFO will review the LDR for any anomalies prior to it being imported into the payroll workbook each pay period. 4. The CFO will review the predetermined program allocations in the payroll workbook monthly to ensure that they are accurate and current. 5. The CFO will compare the employee timesheets, LDR, and payroll expense report to the payroll allocations outlined in the agency budget each month. Person(s) Responsible: Shannon Crocker, CFO Timing for Implementation: Immediately

View Audit 305363

Finding 395730 (2023-005)

Significant Deficiency 2023

Central Montana Medical Center

MT

Questioned Costs Allowable Costs / Cost Principles § 200.303

2023‐005 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: 2 CFR 200.303(a) establis...

2023‐005 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: 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. The Facilities claimed equipment costs under the Provider Relief Fund program for a project that was not complete at the end of the period of availability, or December 31, 2022. Costs were improperly included within the Period 4 report and caused the reporting submitted to the Department of Health and Human Services to be inaccurate. Responsible Individual: Perry Howell, CFO Corrective Action Plan: The Facilities will enhance internal control policies to ensure all amounts are adequately documented and properly recorded in the reports required to be submitted to the federal agency. The Facilities will enhance internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: June 2024

View Audit 305361 Questioned Costs: $1

Finding 395648 (2023-002)

Significant Deficiency 2023

Maine Guaranteed Access Reinsurance Association

ME

Allowable Costs / Cost Principles Significant Deficiency

Finding 2023‐002 Federal Agency Name: U.S. Department of Health and Human Services Pass‐Through Entity: Federal Financial Assistance Listing 93.423 Assistance Listing Number: 1332 State Innovation Waivers Program Name: Maine Guaranteed Access Reinsurance Association (MGARA) Finding Summary: The Asso...

Finding 2023‐002 Federal Agency Name: U.S. Department of Health and Human Services Pass‐Through Entity: Federal Financial Assistance Listing 93.423 Assistance Listing Number: 1332 State Innovation Waivers Program Name: Maine Guaranteed Access Reinsurance Association (MGARA) Finding Summary: The Association’s existing controls over their IT environment for reviewing and reimbursing carriers for claims was not able to detect and prevent a claim from being reimbursed twice.Corrective Action Plan: The duplicate payment to Aetna was requested back to the program and will be received in April 2024. Going forward, the administrator will run reports at the beginning of each calendar year to ensure that all insurance carrier exception reports are generated. This will ensure that whenever claims are processed that all duplicate claims will be identified and denied. Responsible Individual(s): Diane Kopecky, administrator Anticipated Completion Date: April 2024

View Audit 305278

Finding 395596 (2023-001)

Material Weakness 2023

Southwest Organizing Project

IL

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.100 § 200.510

Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in pla...

Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in place by the end of fiscal year 2024. To ensure SEFA will include accurate assisting listing numbers and accurate inclusion of all federal programs. Allowable and unallowable costs will be reviewed to ensure accurate federal expenditure reporting. Edith Robles will perform an exhaustive review of all grants to close out the fiscal year in preparation for the audit process. In addition to these, SWOP will work with a consultant to provide necessary training of finance personnel.

View Audit 305207

Finding 395577 (2023-001)

Significant Deficiency 2023

The Guthrie Clinic

PA

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

Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have inc...

Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have increased the allowable costs eligible for reimbursement under the Federal award by $671. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management implemented an enhanced review process to validate all amounts reported on the PRF Reporting Portal Submission, and to ensure compliance with existing policies and terms and conditions of the Provider Relief Funds. Further action was not considered necessary as the errors would result in increased costs eligible for reimbursement under the Federal award and no further funding is available. Name(s) of Contact Person(s) Responsible for Corrective Action: Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: This was corrected as of June 30, 2023, and the pay for event program was phased-out after the final Provider Relief Funds were released.

View Audit 305185

Finding 395434 (2023-003)

Significant Deficiency 2023

The Literacy Lab

DC

Allowable Costs / Cost Principles § 200.430 § 200.431

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each a...

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each award per employee, as supported by timesheets and other records, we concur with the recommendation and are in the process of creating a single, succinct schedule so that the auditors can easily test and reconcile the salary amounts to the supporting payroll and other records.

View Audit 305163

Finding 395409 (2023-002)

Significant Deficiency 2023

The Literacy Lab

DC

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.302

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization properly apply allowed indirect cost rates across its Federal awards, we concur wi...

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization properly apply allowed indirect cost rates across its Federal awards, we concur with the recommendation and are in the process of creating a single, succinct schedule and the supporting documentation on indirect cost rates and rationale to allow the auditors to easily verify that the costs have been charged appropriately.

View Audit 305163

Finding 395408 (2023-001)

Significant Deficiency 2023

The Literacy Lab

DC

Allowable Costs / Cost Principles § 200.302 § 200.430 § 200.431

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each a...

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each award per employee, as supported by timesheets and other records, we concur with the recommendation and are in the process of creating a single, succinct schedule so that the auditors can easily test and reconcile the salary amounts to the supporting details.

View Audit 305163

Finding 395379 (2023-024)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles § 200.1 § 200.400

2023-024 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program MANAGEMENT RESPONSE: We agree with this recommendation. The ODHS Office of Facilities Management coordinates care of a 168-building portfolio. Part of this work is coord...

2023-024 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program MANAGEMENT RESPONSE: We agree with this recommendation. The ODHS Office of Facilities Management coordinates care of a 168-building portfolio. Part of this work is coordination of furniture reconfiguration, minor and major remodels of office spaces and other building maintenance work. For these projects we rely on program staff with understanding of their funding sources to provide us with accurate coding to support the project related costs. Our office does not work directly with funding source management only coding and billing. To better track who is providing us the coding and maintain a record of payment approval we have revised our workorder form to include who from the program is providing the coding and what authority they have to provide the coding. This will allow us to assure that important details are captured regarding funding application and coding for billing and protect from funds being drawn from sources that do not support and/or are not appropriate for a given project. The questioned costs of $3,849 were corrected and refunded to CMS using document BTCL1485 with a April 17, 2024 effective date. The refund will be reported on the Q3 FFY 2024 CMS 64 which will be submitted by June 30, 2024. Anticipated Completion Date: June 30, 2024 Contact person: Karuna Thompson, Construction and Facilities Maintenance Manager; Travis Labrum, Grant Accounting Manager

View Audit 305129 Questioned Costs: $1

Finding 395367 (2023-037)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles

2023-037 Department of Early Learning and Care Improve controls over payroll MANAGEMENT RESPONSE: We agree with this recommendation. DELC concurs with the findings with the following clarification: position descriptions are typically retained for employees even after they leave employment. Howev...

2023-037 Department of Early Learning and Care Improve controls over payroll MANAGEMENT RESPONSE: We agree with this recommendation. DELC concurs with the findings with the following clarification: position descriptions are typically retained for employees even after they leave employment. However, for the two employees referenced, we were unable to locate their position descriptions. DELC agrees with the stated recommendations and will take the following corrective action steps: • Human Resources will audit all DELC employee records to ensure that positions descriptions are signed, and in the employee’s Workday personnel file. • Human Resources will reiterate expectations to managers to ensure that timesheets are reviewed and approved by managers before the deadline each month. • Budget will monitor payroll charges to identify when time has been incorrectly charged. • DELC will reimburse the federal agency for the known unallowable costs. The anticipated completion date for having signed position descriptions for all DELC employees is December 31, 2024. The agency has already messaged to managers the expectations and importance of reviewing and approving employees time before the deadline each month and will continue to do so monthly prior to each deadline. Anticipated Completion Date: December 31, 2024 Contact person: Heather Thomas, Human Resources Manager; Connie Range, Fiscal Analyst

View Audit 305129 Questioned Costs: $1

Finding 395366 (2023-036)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles

2023-036 Department of Early Learning and Care Improve controls over family copay and child care hour calculations MANAGEMENT RESPONSE: We partially agree with this recommendation. DELC does not concur with the finding regarding a case with the copay amount not reflected in reimbursement between ...

2023-036 Department of Early Learning and Care Improve controls over family copay and child care hour calculations MANAGEMENT RESPONSE: We partially agree with this recommendation. DELC does not concur with the finding regarding a case with the copay amount not reflected in reimbursement between multiple providers. DELC sends out billing forms in advance of the month and providers are allowed to bill for anticipated hours of attendance. We do not require that the primary provider bill, nor can we retroactively reduce the secondary providers payment amount by the copay amount if the primary provider does not bill. DELC has the following language in our ruleset (5b) reflected below, which allows the copay to be zero if the provider to whom the copay is designated does not submit a billing for the month. 414-175-0051 Requirement to Make Copay or Satisfactory Arrangements 1) The Need Group must use a child care provider who meets the requirements in OAR 414-175-0080 and 414-175-0085. 2) The caretaker is responsible for paying the copayment to the primary provider of child care unless the Child Care Billing form was sent to the provider showing no copayment. 3) If the caretaker has only one provider during a month, that provider is the primary provider. If the caretaker uses more than one provider, the caretaker must designate one as the primary provider. Notwithstanding any designation by the caretaker, the Department considers a provider having the copayment amount (not to exceed the caretaker's established copayment amount) deducted from its valid billing statement the primary provider for that period. 4) If the copayment exceeds the amount billed by the primary provider, the Department may treat a different provider as the primary provider or split the copayment among the providers who bill for care. 5) The copayment amount due from the caretaker to the provider is the lesser of: a. The copayment amount determined by the Department based on family size and income. b. The total amount allowed by the Department on a provider claim. DELC does not concur with the finding regarding the overpayment for the months of January, February, and March when the parent changed providers. An overpayment referral was made to the Overpayment Writing Unit in the Oregon Department of Human Services when the new provider was set up. The provider in question did submit billing forms for payment for January, February, and March 2024. When the parent called in late March to end the previous provider, she gave the end date of 1/16/23. The provider was allowed to bill for absent days for the rest of January and the full month of February as absent days. The provider was unable to bill for March since it doesn’t not fall within OAR 414-175-0075 and is considered abandonment of care. DPU made an overpayment referral to the Overpayment Writing Unit when the new provider was set up. The provider was written up for an overpayment for March in the amount of $1,395.00. DELC concurs will all other findings in this area. DELC agrees with stated recommendations and will take the following corrective action steps: • The Child Care Assistance Program team will develop a training partially focused on error trends found in this report to educate staff on findings and preventative measures. • The Child Care Assistance Program team will provide case finding information to OPAR for recoupment purposes. • DELC will reimburse the federal agency for unallowable costs. Anticipated Completion Date: December 31, 2024 Contact person: Regina Siefert, Childcare Policy Analyst

View Audit 305129 Questioned Costs: $1

Finding 395365 (2023-035)

Significant Deficiency 2023

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles

2023-035 Department of Early Learning and Care Use restricted indirect cost rate when required MANAGEMENT RESPONSE: We agree with this recommendation. DELC concurs with these findings; however, the findings are related to the indirect rate charged while the Early Learning Division was part of the...

2023-035 Department of Early Learning and Care Use restricted indirect cost rate when required MANAGEMENT RESPONSE: We agree with this recommendation. DELC concurs with these findings; however, the findings are related to the indirect rate charged while the Early Learning Division was part of the Oregon Department of Education. DELC will continue to work with the Oregon Department of Education to determine if any other indirect costs were incorrectly charged and will help make appropriate corrections to ensure federal grants were not overcharged. We will create processes and procedures to ensure expenditures are allowable before a federal draw is completed and that the correct indirect rate is charged. Anticipated Completion Date: December 31, 2024 Contact person: Natalie Day, Accounting Manager; Connie Range, Fiscal Analyst

View Audit 305129 Questioned Costs: $1

Finding 395341 (2023-042)

Significant Deficiency 2023

State of Oregon

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.439

2023-042 Oregon Department of Education Retain support for pre-approval of equipment purchases MANAGEMENT RESPONSE: We agree with this recommendation. ODE has already developed and implemented updates to the capital expenditure request review and approval process to ensure equipment approvals are...

2023-042 Oregon Department of Education Retain support for pre-approval of equipment purchases MANAGEMENT RESPONSE: We agree with this recommendation. ODE has already developed and implemented updates to the capital expenditure request review and approval process to ensure equipment approvals are retained. Early ESSER capital project tag requests were split between a committee for large projects and the individual grant finance manager. Approvals were primarily sent via email from the grant finance manager. Some of those messages are archived in the ESSER.ODE inbox, however some went out directly from staff email. Records are available for the committee decisions. When the smaller approvals moved from the finance manager to an ESSER team, many of those decisions were made in conjunction with other meetings. Some records are available; however, the Capital Expenditure Tracker was the primary location of decisions. In October 2022, staffing changes allowed the committee and team structure to become more formalized. Committee meeting decisions shifted from a “minute”- style agenda to being more systematized in an online log. Team meeting decisions followed a similar process update in April 2023. The online agenda/log allows for consistent tracking of projects that are up for discussion and which approval are put on hold for elevation approval, correction, or clarification from the district. Committee and team meetings have been established weekly. When all information is received from a district, the project is placed on the appropriate agenda for that week. Approvals are sent out within 2 business days. A column was added to the Capital Expenditure Tracker, which remains the primary location of records, to track when the approval emails were sent. Corrections have already been developed and implemented as of April 2024. Anticipated Completion Date: April 30, 2024 Contact person: Cynthia Stinson, Senior Manager of Federal Investments and Pandemic Renewal Effort

View Audit 305129

Finding 395339 (2023-032)

None 2023

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles

2023-032 Oregon Commission for the Blind Seek clarification from federal awarding agency on appropriateness of legal fees MANAGEMENT RESPONSE: We agree with this recommendation. The agency believes it is allowable to use VR funds for legal fees based upon the guidance provided by 2 CFR § 200.459,...

2023-032 Oregon Commission for the Blind Seek clarification from federal awarding agency on appropriateness of legal fees MANAGEMENT RESPONSE: We agree with this recommendation. The agency believes it is allowable to use VR funds for legal fees based upon the guidance provided by 2 CFR § 200.459, which allows for professional service costs. The agency has previously asked for clarification regarding this issue from the Rehabilitation Services Administration, and we are awaiting their response. We will contact them again requesting clarification. The completion date for this finding is dependent upon receipt of clarification and guidance from the Rehabilitation Services Administration. Anticipated Completion Date: December 31, 2024 Contact person: Dacia Johnson, Executive Director

View Audit 305129 Questioned Costs: $1

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