Corrective Action Plans

Finding 393687 (2023-001)

Significant Deficiency 2023

MI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.405

Finding Number: 2023-001 Condition: VAIA’s controls requiring investigators to monitor expenses, ensure that costs benefitting multiple projects are allocated using a reasonable methodology, as required by Uniform Guidance, and ensure that allocation errors are timely corrected were not supported ...

Finding Number: 2023-001 Condition: VAIA’s controls requiring investigators to monitor expenses, ensure that costs benefitting multiple projects are allocated using a reasonable methodology, as required by Uniform Guidance, and ensure that allocation errors are timely corrected were not supported by adequate training of investigators and their delegates. Planned Corrective Action: VAIA requires laboratory personnel to review and approve monthly Vivarium transactions by protocol, since investigators and their delegates are the only individuals at VAIA in a position to know with certainty how Vivarium costs proportionately benefit multiple funding sources. Following VAIA’s customary review and approval process, VAIA’s internal controls subsequently identified an improperly calculated allocation. Taking swift action, the allocation was corrected, and funds were returned to the Federal Government within 90 days of identifying improper allocation as required by NIH Grants Policy Statement section 7.5. VAIA management disclosed this correction to our external auditors and the award’s Grant Management Officer. VAI’s corrective action plan for Vivarium charges includes the following: - Deploying an automated front-end solution that requires a protocol review and approval by our IACUC office before a protocol is made available for use by individual sponsored projects. - Evaluating additional opportunities to utilize technology to enhance the control environment, particularly with respect to cost allocation of vivarium charges, - Ensuring proper allocation through three meetings per laboratory in 2024 to review Vivarium costs charged to federally sponsored projects. - Providing additional continuing education on cost allocation principles for those making allocation determinations Contact person responsible for corrective action: Craig Reynolds, Vice President for Research Protections Anticipated Completion Date: 12/31/2024

View Audit 303823

Finding 393682 (2023-001)

Material Weakness 2023

Essex North Supervisory Union

VT

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

March 27, 2024 CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) Contact Person Responsible for Corrective Action: Beth Drew, Business Administrator Corrective Action: The Essex North Supervisory Union will take the following actions to address finding 2023-001 – Activities Allowed and Allowable ...

March 27, 2024 CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) Contact Person Responsible for Corrective Action: Beth Drew, Business Administrator Corrective Action: The Essex North Supervisory Union will take the following actions to address finding 2023-001 – Activities Allowed and Allowable Costs: 1. Time sheets will be filled out for all hourly employees 2. Contracts will be issued for all employees and returned signed copies required 3. All invoices will be signed off on by the Business Administrator or Superintendent and dated. 4. Every attempt will be made to do a purchase order for all purchases and to be done before the invoice is recevied Anticipated Completion Date: April 1, 2024

View Audit 303821

Finding 393679 (2023-001)

Significant Deficiency 2023

Berlin Retirement Homes, Inc.

MA

Questioned Costs Allowable Costs / Cost Principles

There will be an extra layer of review added to the current approval process for Accounts Payable.

View Audit 303809 Questioned Costs: $1

Finding 393655 (2023-002)

Material Weakness 2023

Salvation Army of Greater St. Louis

MO

Questioned Costs Allowable Costs / Cost Principles § 200.430

Finding 2023-002: Allowable Costs/Cost Principles (Material Weakness and Noncompliance) Condition: For this program, there was no evidence that actual employee time was tracked, reviewed and approved, or that the actual time spent was used as a basis for allocating personnel charges to the grant. ...

Finding 2023-002: Allowable Costs/Cost Principles (Material Weakness and Noncompliance) Condition: For this program, there was no evidence that actual employee time was tracked, reviewed and approved, or that the actual time spent was used as a basis for allocating personnel charges to the grant. In addition, there was no evidence that actual incurred expenditures were used as a basis for allocating indirect costs to the grant using the negotiated indirect cost rate. Corrective Action Planned: • With input from the Human Resources Department, the Social Services Department and the Grant & Contract Accountants, Management will identify a process for timekeeping for all employees that are allocated to grant/contract budgets. • Once the time-keeping process has been determined, the Grant & Contract Manager and the Divisional Contracts & Grants Compliance Manager will work in tandem to document policies and procedures to ensure employee timekeeping, the salary and wage allocations to the grant, and allocation of indirect costs are charged to the grant using an appropriate base. The written policies and procedures will include, but are not limited to, step-by-step instructions for employees and supervisors, a review/approval process, document retention, and a communication plan. Anticipated Completion Date: June 30, 2024 through September 30, 2024 Name of Contact Person Responsible for the Plan: Elizabeth Sergel

View Audit 303805 Questioned Costs: $1

Finding 393578 (2023-002)

Significant Deficiency 2023

Global Communities

MD

Allowable Costs / Cost Principles Reporting § 200.430

Views of Responsible Officials: Management is committed to having a strong internal control structure that supports compliance with both internal and external policies and procedures. A system for continuous monitoring of the salary allocation process in the Ukraine field office will be implemented ...

Views of Responsible Officials: Management is committed to having a strong internal control structure that supports compliance with both internal and external policies and procedures. A system for continuous monitoring of the salary allocation process in the Ukraine field office will be implemented after additional training is provided. We will provide ongoing support and guidance to staff as they implement the newly acquired ERP system. Management will also conduct periodic evaluations to assess the impact of the training program on internal controls surrounding the salary allocation process.

View Audit 303769

Finding 393490 (2023-005)

Material Weakness 2023

City of Elizabeth

NJ

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

The City recognizes the importance of internal controls and plans to enhance procedures to ensure payroll expenditures related to grants are properly captured, documented, and charged to that grant. Covid interruptions with related illnesses, early retirements, and hiring difficulties all contribut...

The City recognizes the importance of internal controls and plans to enhance procedures to ensure payroll expenditures related to grants are properly captured, documented, and charged to that grant. Covid interruptions with related illnesses, early retirements, and hiring difficulties all contribute to a negative impact on productivity.

View Audit 303684 Questioned Costs: $1

Finding 393406 (2023-002)

Significant Deficiency 2023

Catholic Charities, INC

TN

Allowable Costs / Cost Principles

We are in the process of implementing the MACA method for allocating administrative costs going forward. As part of this process, we completed the MACA worksheet provided by SSVF using fiscal year 2023 data. The resulting allowable administrative costs were actually higher than the actual amounts ch...

We are in the process of implementing the MACA method for allocating administrative costs going forward. As part of this process, we completed the MACA worksheet provided by SSVF using fiscal year 2023 data. The resulting allowable administrative costs were actually higher than the actual amounts charged to the grant for fiscal year 2023. We will continue to work with the Veterans Administration to ensure the allocation methodology complies with the SSVF Program Guide.

View Audit 303656

Finding 393392 (2023-003)

Significant Deficiency 2023

Chippewa Hills School District

MI

Allowable Costs / Cost Principles § 200.402

Finding 2023-003 - Corrective Action Plan CHSD - 2022-2023 Audit Findings Finding 2023-003 – ACTIVITIES ALLOWED OR UNALLOWED / ALLOWABLE COST/COST PRINCIPLES Type: Significant Deficiency in Internal Control Program: COVID 19 Education Stabilization Fund (ALN 84.425D– ESSER II Formula, and ALN 84.425...

Finding 2023-003 - Corrective Action Plan CHSD - 2022-2023 Audit Findings Finding 2023-003 – ACTIVITIES ALLOWED OR UNALLOWED / ALLOWABLE COST/COST PRINCIPLES Type: Significant Deficiency in Internal Control Program: COVID 19 Education Stabilization Fund (ALN 84.425D– ESSER II Formula, and ALN 84.425U – ESSER III Formula) Condition: Expenditures charged to the grant were not authorized by the grant. Criteria: As detailed by 2 CFR 200.402, “the total cost of a Federal award is the sum of the allowable direct and allocable indirect costs less any applicable credits”. Cause: Management’s misunderstanding of costs allowed under this grant. Effect: Unallowed costs Corrective action to be taken: 1. District enlisted the services of an outside consultant to work with the Finance Director to address the training, knowledge, and experience (TKE) shortfalls in his skill set. The scope of work was specified to include addressing the grant funding processes, proper public school audit practices, and the proper methods for grant application, grant budgeting, budget implementation, amending budgetary elements as permissible, and reconciling grant funding. 2. The Finance Director will effectively apply the provided TKE skills to CHSD Grant Funding processes to ensure compliance with the budgetary guidelines and constraints of each grant funding opportunity awarded to the CHSD. 3. In the event a need or opportunity arises, whereby a requested transaction exceeds a budgetary constraint of an approved grant budget, the Finance Director will ensure a Grant Budget Amendment or variance request is reviewed and approved by the issuing Agency/Department prior to authorizing or posting the transaction which would create the budget variance. The corrective action timeline is as follows: The corrective action is effective immediately and applicable to all stakeholders with data entry access to the CHSD financial accounting software platform. District Leader Responsible for Corrective Action Plan: The Finance Director will be responsible for ensuring compliance with this corrective action. Respectfully submitted, Marc Forrest, Director of Finance

View Audit 303635

Finding 393390 (2023-001)

Material Weakness 2023

Chippewa Hills School District

MI

Allowable Costs / Cost Principles § 200.430

Finding 2023-001 - Corrective Action Plan CHSD - 2022-2023 Audit Findings Finding 2023-001 - ACTIVITIES ALLOWED OR UNALLOWED / ALLOWABLE COSTS/COST PRINCIPLES Type: Material Weakness in Internal Control / Noncompliance Program: COVID 19 Education Stabilization Fund (ALN 84.425D – ESSER II Formula, E...

Finding 2023-001 - Corrective Action Plan CHSD - 2022-2023 Audit Findings Finding 2023-001 - ACTIVITIES ALLOWED OR UNALLOWED / ALLOWABLE COSTS/COST PRINCIPLES Type: Material Weakness in Internal Control / Noncompliance Program: COVID 19 Education Stabilization Fund (ALN 84.425D – ESSER II Formula, ESSER II Section 98c Learning Loss, ALN 84.425U – ESSER III Formula) Condition: The District was unable to provide documentation that identified wages, by employee, that were charged to Education Stabilization Fund grants. Corrective action to be taken: Payroll transactions will be recorded at the most granular level to ensure accuracy and transparency in the resulting outcomes. The issue at hand was a result of an overarching labor transfer at the top level of the labor expense accounts. The errant transfer neglected to properly align the underlying transactions, at the employee weekly payroll level, with the correlating expense totals being transferred between grants (i.e. each individual employee expense of the same General Ledger expense code structure comprising the total expense of the given General Ledger) and resulted in the disparity noted in the finding. Adherence to this corrective action will ensure strengthened internal control(s) and future grant compliance. Corrective action timeline: The corrective action is effective immediately and applicable to all stakeholders with data entry access to the CHSD financial accounting software platform. District leader responsible for Corrective Action Plan: The Finance Director will be responsible for ensuring compliance with this corrective action and work product of the Finance Director will have a similarly robust check and balance via transaction review and verification by a knowledgeable second source, normally the Account Payable Administrator or the Superintendent. Respectfully submitted, Marc Forrest, Director of Finance

View Audit 303635

Finding 393276 (2023-001)

Significant Deficiency 2023

Trinity Services, Inc.

IL

Questioned Costs Allowable Costs / Cost Principles Reporting

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. As of the date of the report the Organization has corrected the payroll support file and has...

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. As of the date of the report the Organization has corrected the payroll support file and has attempted to submit a correction to its reporting. The Organization was informed that the matter was closed, and the portal would not be reopened for this correction.

View Audit 303562 Questioned Costs: $1

Finding 393268 (2023-003)

Material Weakness 2023

Midland Area Agency on Aging

NE

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

View of Responsible Officials and Planned Corrective Actions: The Organization is committed to properly tracking and allocating Federal expenditures. The Organization has created adequate internal control processes to ensure expenses are allocated correctly and in accordance with the requirements ...

View of Responsible Officials and Planned Corrective Actions: The Organization is committed to properly tracking and allocating Federal expenditures. The Organization has created adequate internal control processes to ensure expenses are allocated correctly and in accordance with the requirements of the Uniform Guidance.

View Audit 303547

Finding 393201 (2023-007)

Significant Deficiency 2023

State of New Jersey

NJ

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

The Department of Human Services (DHS), Central Office Payroll group will run reports biweekly to determine if any employees are on a leave without pay status greater than 10 days. This added reporting function will ensure that all DHS employees who are on a leave of absence without pay beyond 10 d...

The Department of Human Services (DHS), Central Office Payroll group will run reports biweekly to determine if any employees are on a leave without pay status greater than 10 days. This added reporting function will ensure that all DHS employees who are on a leave of absence without pay beyond 10 days have their PMIS histories updated upon each extension and return to work. COMPLETION DATE/ CONTACT PERSON March 26, 2024 Maureen Taylor (609) 292-6106 Maureen.Taylor@dhs.nj.gov

View Audit 303516 Questioned Costs: $1

Finding 393176 (2023-001)

Significant Deficiency 2023

Mount Mansfield Unified Union School District

VT

Allowable Costs / Cost Principles School Nutrition Programs § 200.303 § 200.430

Contact Person Responsible for Corrective Action: Nicole Fortier, Director of Finance and Operations Corrective Action: During our audit it was identified that MMUUSD overpaid an employee for four charges under the Food Service program and charged the work to the program that was not specific to Foo...

Contact Person Responsible for Corrective Action: Nicole Fortier, Director of Finance and Operations Corrective Action: During our audit it was identified that MMUUSD overpaid an employee for four charges under the Food Service program and charged the work to the program that was not specific to Food Service. To be more specific, Food Service subs were paid at a higher rate ($.50 higher) than the stated rate for a Food Service substitute. Additionally, there were instances noted where a maintenance substitute was charged to a Food Service budget unit. The first step in our corrective action plan was a review with our Senior Payment Specialist of the importance of slowing down and verifying the correct hourly rate being input for our substitutes. This step has already been completed. Additionally, we are in the process of implementing a more thorough payroll review process, which will include a preliminary review by Christal Clark, Accountant in the Business Office. Once Christal has completed her review, this will go to Nicole Fortier, Director of Finance for a final, high‐level review and sign off. We are hopeful to begin the process at the end of FY24, with full implementation in FY25. Anticipated Completion Date: 7/01/2024

View Audit 303494

Finding 393055 (2023-003)

Significant Deficiency 2023

Interfaith Works, Inc.

MD

Special Tests & Provisions Allowable Costs / Cost Principles HUD Housing Programs

Views of Responsible Officials: IW is utilizing a procedure to ensure that procured units are compliant with rent reasonableness standards. Currently, the Housing Locator identifies rental units of similar size and within a similar geographic region. The asking rental cost for each unit is compared ...

Views of Responsible Officials: IW is utilizing a procedure to ensure that procured units are compliant with rent reasonableness standards. Currently, the Housing Locator identifies rental units of similar size and within a similar geographic region. The asking rental cost for each unit is compared to the daily FMR rate. Based on the audit results we have revised this procedure to include documentation of this process in a spreadsheet. The unit once chosen by the client will be clearly indicated. The rent reasonableness rate during the selection period will also be indicated on the spreadsheet.

View Audit 303346

Finding 392991 (2023-001)

Significant Deficiency 2023

Baystate Medical Center, Inc.

MA

Reporting Allowable Costs / Cost Principles Special Tests & Provisions § 200.302

Finding 2023‐001—Significant Deficiency in Internal Controls over Compliance: Research and Development Cluster Contact Person: Melissa Quintero, Director, Sponsored Programs Administra􀆟on and Peter D. Friedmann, Chief Research Officer, Baystate Health. Views of Responsible Officials: Management agre...

Finding 2023‐001—Significant Deficiency in Internal Controls over Compliance: Research and Development Cluster Contact Person: Melissa Quintero, Director, Sponsored Programs Administra􀆟on and Peter D. Friedmann, Chief Research Officer, Baystate Health. Views of Responsible Officials: Management agrees and acknowledges that well‐defined roles, responsibili􀆟es, processes, and monitoring are necessary. Management wishes to highlight that no unallowable charges were incurred as a result of the iden􀆟fied deficiencies. Correc􀆟ve Ac􀆟on Plan and Expected Comple􀆟on Date Roles and Responsibili􀆟es—Management has engaged Huron Consul􀆟ng Group (Huron) to review roles and responsibili􀆟es across Sponsored Programs Administra􀆟on (SPA), Research Accoun􀆟ng and other affected areas to ensure adequate defini􀆟ons and clarity across control owners. Huron’s recommenda􀆟ons should be available by April 11, 2024. Once Huron’s recommenda􀆟ons are received and reviewed by management, posi􀆟on descrip􀆟ons will be revised, new posi􀆟ons created, and training implemented to ensure personnel understand their role and responsibili􀆟es related to internal controls, including controls over compliance and documenta􀆟on requirements. Policies and Procedures—Management maintains policies and procedures that govern the conduct of grantrelated ac􀆟vi􀆟es. Policies and procedures will be updated following Huron’s review of the roles and responsibili􀆟es, and management will con􀆟nue to make addi􀆟onal updates as necessary. Personnel will be trained on relevant updated policies and procedures. Documenta􀆟on and Document Maintenance—Management has ini􀆟ated implementa􀆟on of ServiceNow to improve the consistency and accessibility of documenta􀆟on evidencing review over research and development (R&D) compliance requirements and performance of internal control procedures. ServiceNow is a cloud‐based pla􀆞orm that will allow for the opera􀆟on of 􀆟cket‐based help desk func􀆟onality for SPA. This system will replace the large volume of email communica􀆟ons that currently documents a significant propor􀆟on of internal control ac􀆟vity and solve the problem of such emails lost to incomplete archiving and Baystate’s email reten􀆟on policy. SPA has a Microso􀅌 Teams central repository for all award‐related documents, as well as any legacy email and other documenta􀆟on related to compliance requirements and internal controls over compliance. Salary Cap—Management will re‐emphasize to end‐users via wri􀆩en communica􀆟on that the quarterly Excel summary report of salary cap is a courtesy report only, and that end‐users should rely on Infor Lawson as the system of record and its (1) Labor Cost by Ac􀆟vity report for labor cost and (2) Ac􀆟ve 10.2 report for salary cap distribu􀆟on and valida􀆟on. Prior to the quarterly mee􀆟ngs with the Departments and Service Lines to review award ac􀆟vity and expenditures, SPA and Research Accoun􀆟ng will compare the Excel summary with the two Infor Lawson reports for accuracy, inves􀆟gate and resolve differences in a 􀆟mely manner, and document evidence of review in SPA’s Microso􀅌 Teams site. Indirect Cost and Fringe Benefit Review—Due to the manual nature of entering and maintaining award data in the financial system, complete accuracy in data capture con􀆟nues to be an ongoing goal and objec􀆟ve. Management will develop and implement a checklist to enhance the review of internal controls associated with the SPA form maintained in IRBNet prior to submission to Finance. Documenta􀆟on of this review will be maintained in the Microso􀅌 Teams central repository. SPA has ac􀆟vated in IRBNet a system‐generated email alert that will be sent to Research Accoun􀆟ng on the comple􀆟on of the SPA form to enable the account set up step to be ini􀆟ated or revised, as required. SEFA Review—An enhanced monthly Infor Lawson report and a quarterly schedule of expenditures of federal awards (SEFA) report from Research Accoun􀆟ng has been added to the SPA’s quality assurance process to ensure 􀆟mely review of the SEFA data to improve accuracy. All quality assurance reports are available monthly a􀅌er the month end close. These reports will be reviewed by SPA and Research Accoun􀆟ng for accuracy and retained in SPA’s Microso􀅌 Teams site with evidence of review. Management expects to complete the above ac􀆟ons by December 31, 2024.

View Audit 303323

Finding 392935 (2023-002)

Material Weakness 2023

City of Columbus, Ohio

OH

Allowable Costs / Cost Principles § 200.303 § 200.430

Finding Number: 2023-002 Planned Corrective Action: The City concurs with the finding and will take the following actions in response: Provide training in the Department of Development (DOD) that reminds applicable staff of the department’s policy that all personal activity reports/work logs are to...

Finding Number: 2023-002 Planned Corrective Action: The City concurs with the finding and will take the following actions in response: Provide training in the Department of Development (DOD) that reminds applicable staff of the department’s policy that all personal activity reports/work logs are to be reviewed and signed by the supervisor within one week of the completion of a pay period. Modify current financial management internal controls to indicate that if a work log is not signed by the supervisor at the time DOD Fiscal Office completes the quarterly ‘tru up’, a ‘tru up’ for unsigned activity reports/work logs shall not be done at that time, thereby reducing the risk of ineligible expenses, and all worklogs must be signed by the time designated by DOD Fiscal Office near the end of the fiscal year; and DOD Fiscal Office staff shall review signature timeliness as a part of the quarterly ‘tru up’ process and provide a report to department leadership who shall determine the appropriate next steps if activity reports/work logs are unsigned. Anticipated Completion Date: 4/30/2024 Responsible Contact Person: Bill Webster, Deputy Director Alex Cofield, Development Program Coordinator/Compliance and Data Analytics

View Audit 303212

Finding 392908 (2023-002)

Significant Deficiency 2023

Rosemont College of the Holy Child Jesus

PA

Student Financial Aid Procurement, Suspension & Debarment Allowable Costs / Cost Principles

When SAP is run in the spring, students will be notified of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic ...

When SAP is run in the spring, students will be notified of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic plan must be signed by both the student and advisor. The academic plan must be submitted to the Office of Financial Aid via the teams. A financial aid hold will be placed on the student's account until the signed academic plan is received. Once received, the Office of Financial Aid will remove the hold so the student can be awarded.

View Audit 303193

Finding 392811 (2023-002)

Significant Deficiency 2023

Lss Manor, Inc. - New Berlin

WI

HUD Housing Programs Allowable Costs / Cost Principles

Federal Award Findings and Questioned Costs: During the 2023 financial statement audit, it was brought to management's attention that the Project was overcharged salary and related benefits. The amount of questioned cost totaled $21,005 which was identified during the audit and was corrected by mana...

Federal Award Findings and Questioned Costs: During the 2023 financial statement audit, it was brought to management's attention that the Project was overcharged salary and related benefits. The amount of questioned cost totaled $21,005 which was identified during the audit and was corrected by management during the year ending December 31, 2023. Corrective Response: Leadership training around the importance of proper time allocation and methods for tracking and confirming proper time recording was held in January of 2024. LSS payroll department leadership presented this training in conjunction with housing department senior leadership. All LSS HUD property management staff is scheduled to receive this training in March of 2024. In addition, all HUD property managers were provided copies of their budgeted hours for each of their Projects. HUD property management staff was reminded of the importance of striving to stay within those hours, and of proactively working with leadership should project needs necessitate change. Housing Senior Leadership meets monthly with HUD leadership. In these meetings emphasis will be placed on reviewing actual versus budgeted results related to payroll costs. Leadership will work with LSS finance staff to investigate the validity in variances identified. Anticipated completion date: 6/30/2024 Responsible Contact Person: Randy Oleszak CFO 414-246-2353

View Audit 303143

Finding 392630 (2023-001)

Material Weakness 2023

Community Housing Solutions

OH

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

The finding from the schedule of findings and questioned costs for the year ended December 31, 2023 are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. Finding 2023-001 Condition: The Organization does not have proper segregation of duties and app...

The finding from the schedule of findings and questioned costs for the year ended December 31, 2023 are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. Finding 2023-001 Condition: The Organization does not have proper segregation of duties and appropriate level of review and approval prior to charging costs to a federal program. The same individual was approving timecards and reimbursement packets without an additional layer of review. Additionally there was no documentation of review of the reimbursement packets prior to being submitted for reimbursement. Planned Corrective Action: Management has implemented a process to ensure review of the reports prior to finalization and submission to the funder. One person will gather data and appropriate paperwork for reporting and reimbursement purposes. To ensure proper segregation of duties, there will be 2 different individuals that approve timecards and gather reimbursement packets. In addition, a second person will review and approve completed reports and packet prior to submission. This review process will be properly documented and evidenced through signature of the reports. Anticipated Completion Date: March 31, 2024 Contact Person: Pam Schuellerman, Executive Director

View Audit 302933

Finding 392618 (2023-002)

Material Weakness 2023

River Valley Local School District

OH

Questioned Costs Allowable Costs / Cost Principles § 200.439

The River Valley Board of Education acknowledges that the Federal government requires school districts to get approval for any purchases with a unit cost of $5,000 or more from the federal awarding agency or pass-through entity. The Board and Administration have implemented processes and procedures,...

The River Valley Board of Education acknowledges that the Federal government requires school districts to get approval for any purchases with a unit cost of $5,000 or more from the federal awarding agency or pass-through entity. The Board and Administration have implemented processes and procedures, which require approval from both the awarding agency or pass-through entity and the Board of Education prior to purchasing any unit at or above the $5,000 threshold.

View Audit 302921 Questioned Costs: $1

Finding 392509 (2023-013)

Material Weakness 2023

Park County

MT

Allowable Costs / Cost Principles Cash Management

NONCOMPLIANCE WITH ALLOWABLE COSTS/COST PRINCIPLES; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No’s 112761 AND 112626, YEAR ENDED JUNE 30, 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop a process to ver...

NONCOMPLIANCE WITH ALLOWABLE COSTS/COST PRINCIPLES; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No’s 112761 AND 112626, YEAR ENDED JUNE 30, 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop a process to verify that amounts reported to the granting agency agree to the general ledger accounting records. Proposed Completion Date: This meeting will take place in January 2024 to develop those procedures.

View Audit 302840

Finding 392216 (2023-001)

Significant Deficiency 2023

Appalachian Regional Healthcare System, Inc.

GA

Questioned Costs Allowable Costs / Cost Principles Reporting

FINDINGS - FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2023-001 COVID-19 Provider Relief Fund (PRF) – Period 4 Recommendation: • We recommend the System design and implement controls, including levels of review, to ensure qualifying expenses submitted are in accordance with the HHS guideli...

FINDINGS - FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2023-001 COVID-19 Provider Relief Fund (PRF) – Period 4 Recommendation: • We recommend the System design and implement controls, including levels of review, to ensure qualifying expenses submitted are in accordance with the HHS guidelines with supporting documentation retained. • Action Taken: Management agrees with this finding as stated and the additional actions that will be taken by the System. Management will design controls to establish an adequate review process to ensure consistent and accurate calculations and reconciliations in accordance with HHS guidelines. Rick Cassady, CFO

View Audit 302428 Questioned Costs: $1

Finding 392144 (2023-003)

Significant Deficiency 2023

City of Baldwin Park

CA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.300 § 200.306 § 200.308 § 200.309 § 200.403

2023-003 - Allowable Costs/Cost Principles – Internal Control and Compliance over Allowable Costs/Cost Principles (Significant Deficiency) Condition: During our audit, we noted that three (3) out of forty (40) samples summed up to $39,055.50 had no proper source documents to support the transaction...

2023-003 - Allowable Costs/Cost Principles – Internal Control and Compliance over Allowable Costs/Cost Principles (Significant Deficiency) Condition: During our audit, we noted that three (3) out of forty (40) samples summed up to $39,055.50 had no proper source documents to support the transactions charged to the grant brought by lost official receipts, hence, identified as not adequately documented. Alternatively, the City created a memo to document the loss of receipts signed by the department head. Management concurs. Corrective Actions: The City has an existing purchasing policy and procedures requiring documentation of all purchases made. Finance department has already sent a reminder to all department heads regarding the policy and procedure and why they must comply. Implemented Name of Responsible Person: Manuel Carrillo Jr., Director of Recreation & Community Services

View Audit 302364 Questioned Costs: $1

Finding 392140 (2023-002)

Significant Deficiency 2023

City of Baldwin Park

CA

Questioned Costs Allowable Costs / Cost Principles § 200.430

2023-002 - Allowable Costs/Cost Principles – Internal Control and Compliance over Payroll Expenditures (Significant Deficiency) Condition: Community Development Block Grants-Entitlement Grants Cluster We determined the City did not comply with federal requirements for direct payroll charges. Payrol...

2023-002 - Allowable Costs/Cost Principles – Internal Control and Compliance over Payroll Expenditures (Significant Deficiency) Condition: Community Development Block Grants-Entitlement Grants Cluster We determined the City did not comply with federal requirements for direct payroll charges. Payroll costs for all eight employees tested were allocated to programs based on percentages provided by management. These allocations were not supported by approved time samples or updated cost allocation methods/plan, nor were they reconciled to actual time spent on the various programs. Employee timesheets did not record the actual labor efforts expended on these grants. In April 2023, the City has required all Housing Department staff to retrospectively fill out timesheets pertaining to actual hours worked on the program during fiscal year 2023, The City performed reconciliation on Housing Department staff payroll charges to reflect actual hours worked. However, the admin supporting staff did not use the same method due to the low percentage of the payroll charges to the grant. Housing Voucher Cluster We determined the City did not comply with federal requirements for direct payroll charges. Payroll costs for all five employees tested were allocated to programs based on percentages provided by management. These allocations were not supported by approved time samples or updated cost allocation methods/plan, nor were they reconciled to actual time spent on the various programs. Employee timesheets did not record the actual labor efforts expended on these grants. In April 2023, the City has required all Housing Department staff to retrospectively fill out timesheets pertaining to actual hours worked on the program during fiscal year 2023, The City performed reconciliation on Housing Department staff payroll charges to reflect actual hours worked. However, the admin supporting staff did not use the same method due to the low percentage of the payroll charges to the grant. Management Comment. City Response and Corrective Action: Management has enforced the existing policy, which mandates that employees funded by federal grants document the actual time they spend working on those grants. The staff responsible for reporting the actual time spent on federally funded programs dedicate a significant portion of their time to these programs. However, there are administrative staffs that provide support towards these programs, and tracking their time spent towards the time spent on the program would require more time and effort than the minimal allocation the City allocated for each administrative staff as appropriated in the Adopted Budget. The minimal cost allocated towards the program is significantly less than the actual time spent as well as being below the 10 percent de-minimis indirect rate as mentioned in Note 4 on the FY 2022-23 Single Audit. Management will have supporting administrative staff to keep track of their actual work hours moving forward and/or establish an indirect cost allocation plan moving forward. Name of Responsible Person: Ron Garcia, Director of Community Development Imelda Delgado, Housing Manager Rose Tam, Director of Finance Albert Trinh, Accounting Manager

View Audit 302364 Questioned Costs: $1

Finding 392120 (2023-001)

Significant Deficiency 2023

Adkins Village Non‐profit Housing Corporation

MI

Allowable Costs / Cost Principles Reporting Significant Deficiency

March 6, 2024 Adkins Village Non-Profit Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E Grand River Ave, Suite 1 Lansing, Michigan 48912 Audit Period: The finding from the December 31, 2023 schedule ...

March 6, 2024 Adkins Village Non-Profit Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E Grand River Ave, Suite 1 Lansing, Michigan 48912 Audit Period: The finding from the December 31, 2023 schedule of findings and questioned costs is discussed below. The finding is number consistently with the number assigned in the schedule. Finding - Federal Awards Finding 2023-001 – Significant Deficiency Recommendation: We recommend the Organization put procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. Action to be Taken: The Organization concurs with the facts of this finding and has put procedures

View Audit 302288

Corrective Action Plans

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