Corrective Action Plans

Finding 391558 (2023-002)

Material Weakness 2023

NY

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2023-002 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): This FY23 audit was conducted on the heels of the FY22 audit where the questioned cost finding is a similar er...

Finding No. 2023-002 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): This FY23 audit was conducted on the heels of the FY22 audit where the questioned cost finding is a similar error type but significantly decreased to $296 from over $18,000. Included in the FY22 recommended Corrective Action was the onboarding of the Executive Director to shepherd the charge with strengthening the teams’ internal governance, appropriate monitoring and future compliance. Adversely, the onboarding of the executive director was lengthy and only recently finalized in the 2nd quarter of FY24. HRA agrees to strengthen internal controls and the new Executive Director is working with the team to ensure they are intentional in appropriately applying the correct formula for calculating allowable cost, particularly the inclusion of “gross” and not “net” income. The Quality Assurance Tool has been updated including specific sub-items to ensure allowable cost is correctly calculated as well as the other deliverables. Corrective Action(s) • Strengthen internal governance and future compliance. • Executive Director for the Home-TBRA now on board. • Update the Quality Assurance tool that includes sub-items information that supports improved review and approval. • Provide refresher training for staff involved with TBRA to improve performance and outcomes. Anticipated Completion Date: June 30, 2024 and ongoing Person(s) Responsible for Implementation: Dori Hopkins-Figeroux, Director - HTBRA hopkinsfigerouxd@hra.nyc.gov 929-252-6089 Jordan Worrell, Executive Director RAP/HTBRA worrellj@hra.nyc.gov 929-252- 5403 Dwana Abraham, Assistant Deputy Commissioner abrahamd@hra.nyc.gov 929-221-6726

View Audit 302042 Questioned Costs: $1

Finding 391469 (2023-002)

Material Weakness 2023

Legal Aid Soceity of Hawaii

HI

Allowable Costs / Cost Principles

Management concurs with the finding listed above. Corrective Action Plan: Management will continue its ongoing process of hiring one new full-time Accountant with solid accounting and GAAP knowledge. Management will also continue to utilize the expertise provided by the current temporary Accountant...

Management concurs with the finding listed above. Corrective Action Plan: Management will continue its ongoing process of hiring one new full-time Accountant with solid accounting and GAAP knowledge. Management will also continue to utilize the expertise provided by the current temporary Accountant in areas of MIP internal operations to reconcile monthly account balances, especially the Cash accounts, to ensure that timely reconciliation of all account balances happen on a monthly basis and then at year end. Individuals responsible: Jim Gagne, Director of Finance. Anticipated completion date: June 30, 2024.

View Audit 301952

Finding 391465 (2023-002)

None 2023

City of Westminster, Maryland

MD

Questioned Costs Allowable Costs / Cost Principles

The City has developed a time study that will be completed by the Director of Housing one week per quarter. This time study will identify the Director of Housing's time spent on HUD vs. other activities and the percentage of time spent on HUD will be used to appropriately allocate the Director of Ho...

The City has developed a time study that will be completed by the Director of Housing one week per quarter. This time study will identify the Director of Housing's time spent on HUD vs. other activities and the percentage of time spent on HUD will be used to appropriately allocate the Director of Housing's salary and benefit costs to the HUD program. The initial time study was completed in January 2024; another will be done in April 2024. These will be used to allocate The Director of Housing's salary and benefits for FY24.

View Audit 301948 Questioned Costs: $1

Finding 391447 (2023-005)

Significant Deficiency 2023

Area Four Senior Citizens Planning Council, Inc.

SD

Allowable Costs / Cost Principles Significant Deficiency

Current Audit Finding: 2023-005 – Department of Health and Human Services Passed through the State of South Dakota Department of Human Services Special Programs for the Aging - Title III, Part C - Nutrition Services #93.045 Nutrition Services Incentive Program #93.053 Award # 24SC193061 Awar...

Current Audit Finding: 2023-005 – Department of Health and Human Services Passed through the State of South Dakota Department of Human Services Special Programs for the Aging - Title III, Part C - Nutrition Services #93.045 Nutrition Services Incentive Program #93.053 Award # 24SC193061 Award Year – 2024 Award # 23SC193061 Award Year – 2023 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: In testing, it was noted that 3 invoices that were paid with electronic payment were not approved prior to payment being made. Responsible Individual: Marla Kiesz, Executive Director Corrective Action Plan: Due to cost considerations and limited accounting staffing, we are aware of the condition and mitigate it with oversight from management and the Board of Directors and review of the transactions in each fund to ensure all entries are posted and paid as anticipated. Anticipated Completion Date: ongoing

View Audit 301941

Finding 391445 (2023-002)

None 2023

Cobb County Board of Health

GA

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

Views of Responsible Officials and Planned Corrective Action: The Board agrees with this recommendation and will review internal procedures relating to data that will support the allocation of personnel costs.

View Audit 301940 Questioned Costs: $1

Finding 391440 (2023-001)

Significant Deficiency 2023

Community Action Partnership of Oregon

OR

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Corrective Action: Susan Matlack Jones (SMJ) took over as CAPO’s fiscal service provider in July of 2022. The first six months were spent largely cleaning and correcting journal entries from FY22 – a significant task. CAPO did not begin to receive truly accurate and trustworthy financial statements ...

Corrective Action: Susan Matlack Jones (SMJ) took over as CAPO’s fiscal service provider in July of 2022. The first six months were spent largely cleaning and correcting journal entries from FY22 – a significant task. CAPO did not begin to receive truly accurate and trustworthy financial statements until early in 2023. CAPO also experienced two staff losses in the finance department from March through May of 2023. In light of our growth and increased administrative needs, we revised our job posting to increase the level of fiscal skill and responsibility needed for the Finance Manager role. In September of 2023, CAPO was successful in hiring a Finance and Grants Manager with experience in federal fund accounting for Community Action and in SSVF (our major grant). Since that time, he has organized, revamped, and significantly improved internal processes to assure timely review of all finances and reconciliations and works closely with SMJ to assure overall accuracy. Person Responsible: Janet Allanach, CAPO Executive Director Timing for Implementation: Complete as of October 2023

View Audit 301926

Finding 391403 (2023-002)

Significant Deficiency 2023

County of Nevada

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.403 § 200.430 § 200.431

The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are r...

The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are recognized in accordance with cost principles, statues, regulations, and terms and conditions of federal awards.

View Audit 301919

Finding 391380 (2023-004)

Significant Deficiency 2023

Ifoster, Inc.

CA

Allowable Costs / Cost Principles Significant Deficiency § 200.430

Finding 2023-004 Federal Agency Name: U.S. Department of Labor Pass-Through Entity: State of Washington – Service Washington, State of California – California Volunteers, State of Kentucky – KY Cabinet of Health and & Family Services Assistance Listing Number: 94.006 Program Name: AmeriCorps State a...

Finding 2023-004 Federal Agency Name: U.S. Department of Labor Pass-Through Entity: State of Washington – Service Washington, State of California – California Volunteers, State of Kentucky – KY Cabinet of Health and & Family Services Assistance Listing Number: 94.006 Program Name: AmeriCorps State and National Finding Summary: Title 2 U.S. Code of Federal Regulations (CFR) Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) section 200.430 provides that records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Amounts for certain personnel costs were not reimbursed at the correct pay rate for certain employees. Responsible Individuals: Reid Cox, CFO Corrective Action Plan: Acknowledged. While current year differences were immaterial and resulted in a slight underbilling, we have implemented a secondary review process of all calculations of hourly payrates to ensure consistency in the payrate calculation. Anticipated Completion Date: Ongoing

View Audit 301914

Finding 391374 (2023-005)

Significant Deficiency 2023

Board of Education of Prince George's County Maryland

MD

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.344

Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit fin...

Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024

View Audit 301912 Questioned Costs: $1

Finding 391341 (2023-004)

Significant Deficiency 2023

Board of Education of Prince George's County Maryland

MD

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.344

Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is...

Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024

View Audit 301912 Questioned Costs: $1

Finding 391338 (2023-001)

Material Weakness 2023

Lifespire, Inc.

NY

Allowable Costs / Cost Principles Reporting

The main reason for the discrepancy in income was a result of using actual units/services billed (from the billing software) and not what is recorded in the financials because, usually what is recorded every month in the financials is based on estimates and later adjusted based on actual billing and...

The main reason for the discrepancy in income was a result of using actual units/services billed (from the billing software) and not what is recorded in the financials because, usually what is recorded every month in the financials is based on estimates and later adjusted based on actual billing and payments for services received. With this approach we were comfortable that, if necessary, we could trace the income to the actual service rather than an estimate. An unintended consequence was that income received in a year for a service in a prior year was not accounted for. While, immaterial, this resulted in discrepancies. We are committed that in the future, we would take additional steps to review the information by other employees who are not involved in the process in order to get a different perspective, and seek outside help, like a CPA, if necessary.

View Audit 301904

Finding 391323 (2023-005)

Material Weakness 2023

Ashley Medical Center

ND

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

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lo...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lost revenue ca lculation option i which is actual to actual methodology of calculating lost revenues attributable to coronavirus. The Medical Center did not incorporate the financial audit adjustments into the actual revenue amounts reported within the HHS special report for the fiscal years 2019, 2020, and 2021. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure the lost revenue calculation is supported by internal financia ls. We will also implement control policies to ensure a secondary review and approval over the final lost revenue calculation. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391322 (2023-004)

Material Weakness 2023

Ashley Medical Center

ND

Allowable Costs / Cost Principles § 200.303

Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and Reporting Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Cen...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and Reporting Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center's final expenditure listing, lost revenue calculation identified as eligible and claimed under the Provider Relief Fund program, and special report submitted to the Department of Health and Human Services for Period 4 did not have evidence of being reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Cory Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure all invoices are reviewed and approved to ensure all expenses claimed under the federal program are necessary, correct, and meet the requirements of the federal program. We will also implement a control process which includes a secondary review and approval of the final expenditure listing and lost revenue calculation used to claim the allowable costs under the federal program and that there is documented evidence of the review and approval. In addition, the Report submitted to HHS will have a secondary review and approval that is documented. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391321 (2023-003)

Material Weakness 2023

Ashley Medical Center

ND

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

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center does not ha...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center does not have an adequate internal control policy in place to ensure review and approval of cash disbursements claimed under the federal programs were documented and to ensure that expenses claimed in the Report were complete, accurate, and reduced by other funding sources. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure all amounts reimbursed by other funding sources are adequately documented and reduced from the eligible expenditure listing and are properly recorded in the Report required to be submitted to the federal agency. We will also implement internal control policies to ensure that the required Report 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 Report required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391264 (2023-001)

Significant Deficiency 2023

The Children's Home Society of Florida

FL

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.403 § 200.430

Identifying Number: 2023-001 – Activities Allowed or Unallowed; Allowable Costs/Costs Principles Finding: The Code of Federal Regulations (CFR) Section 200.403(g) states that for costs to be allowable under federal awards, they must be adequately documented and there must be sufficient documentation...

Identifying Number: 2023-001 – Activities Allowed or Unallowed; Allowable Costs/Costs Principles Finding: The Code of Federal Regulations (CFR) Section 200.403(g) states that for costs to be allowable under federal awards, they must be adequately documented and there must be sufficient documentation. Additionally, CFR Section 200.430 states that charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed and are supported by a system of internal control which provides reasonable assurance that the charges are accurate and allowable. The Florida’s Division of Accounting and Auditing Reference Guide for State Expenditures states that supporting documentation shall be maintained in support of expenditure payment requests for cost reimbursement contracts including that approved timesheets support the hours worked on the project or activity must be kept. During our testing of payroll disbursements, we noted that seven of the 120 payroll expenditures selected for testing did not have a properly approved timecard for the pay period selected. Corrective Actions Taken or Planned: All of the timecards noted in the finding above have been reviewed for accuracy and retroactively approved by the Chief Talent Officer. The following corrective actions are in the process of being implemented: • CHS’s Payroll and Talent teams will conduct a review of timecards completed after July 1, 2023. The accuracy of any unapproved timecards identified will be verified and retroactively approved by the designated supervisor, or the Chief Talent Officer if the designated supervisor is no longer available. • After each payroll period, a list of unapproved timecards will be provided to the Talent Team so the respective Talent Business Partner may follow up with corrective action with those supervisors who have two or more repeat occurrences. Such corrective action will include: o A thorough review with the supervisor of the CHS policies and practices relative to supervisory duties regarding the management and approval of employee timecards. o Mandatory refresher education and training on the supervisory timecard review and approval process in the CHS HRIS, Paylocity. In addition, CHS is formally implementing a new HRIS, UKG PRO, in July 2024. This system has advanced notification and tracking features that will assist supervisors in proper management and approval of timecards. Person(s) Responsible for Corrective Actions: Barbara McDonald, Chief Financial Officer and Chief Administrative Officer and Heather Vogel, Chief Talent Officer Anticipated Completion Date for Corrective Actions: Implementation of the Corrective Actions outlined above will begin immediately to be completed by June 30, 2024.

View Audit 301878

Finding 391208 (2023-001)

Material Weakness 2023

Higher Horizons Day Care Center, Inc.

VA

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

Based on FY2022 findings, Higher Horizons implemented internal control policies and procedures, effective May 1, 2023. The procedures address all the segregation of duties from journal entries to posting, reconciliation to reporting, and access to the accounting software. The implementation of the i...

Based on FY2022 findings, Higher Horizons implemented internal control policies and procedures, effective May 1, 2023. The procedures address all the segregation of duties from journal entries to posting, reconciliation to reporting, and access to the accounting software. The implementation of the internal control policies and procedures were initiated in May and June of 2023 (the last two months of FY 2023). During FY2024, these procedures were enforced to mitigate risks due to lack of sound internal control. To further strengthen the internal control system, Higher Horizons changed the requisition and accounts payable paper-based to paperless (electronic) process effective July 1, 2023. The electronic requisition system (Microix) is integrated with the accounting software (Abila), which has noticeably enhanced the internal control system.The Microix electronic requisition system eliminates the need to monitor the flow of paper documents, eliminates the risk of losing documents, and disallows purchases without approval. Microix features also require allowability of requisitions to be determined, all changes & communications to be captured, eliminates re-keying the information into Abila, minimizes manual interventions in entering & posting transactions, and much more. Higher Horizons will continue assessing & monitoring the effectiveness of our internal control, review the outcomes, and as needed, will further strengthen the process. Higher Horizons will monitor individual access to general ledger, subsidiary ledger, assets of the organization, accounting software, and Paycom. Access control procedures will be developed and implemented before the end of May 2024. As indicated in FY2023 audit findings, one of the causes for inadequate segregation of duties is the small number of staff in the Finance Department. Higher Horizons will contract with a finance consultant to review the current finance department staffing structure. The consultant will provide feedback and recommendation for adequately staffing the finance department to ensure segregation of duties. The finance management staff will conduct a comprehensive study of accounting and financial tasks, policies and procedures, and standard operating procedures by contracting the financial consultant before the end of June 2024. The study will be presented to the Board for approval, and OFC and OHS for funding.

View Audit 301845

Finding 391202 (2023-001)

Significant Deficiency 2023

Chicago Association for Retarded Citizens

IL

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

Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2022 – 06/30/2023 Contract Number: FSCWJ00302 Award Year: 2022 – 2023 Comments on Findings and Recommendations: Finding 2023-001—Certification over payroll cost allocation (Control Finding)— Envision Un...

Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2022 – 06/30/2023 Contract Number: FSCWJ00302 Award Year: 2022 – 2023 Comments on Findings and Recommendations: Finding 2023-001—Certification over payroll cost allocation (Control Finding)— Envision Unlimited allocated staff salaries and related fringe benefits to the federal program based on budgeted estimates, which were determined before the services were provided. There was no employee certification or documented review of actual time and effort incurred for the payroll costs charged to the grant at the time audit procedures were performed. 2 CFR 200.430(i) Standards for Documentation of Personnel Expenses (1) Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to federal awards, but may be used for interim accounting purposes, provided that the non-federal entity's system of internal controls includes processes to review after-the-fact interim charges made to a federal award based on budget estimates. All necessary adjustments must be made such that the final amount charged to the federal award is accurate, allowable, and properly allocated. Action Taken- Employee certifications were obtained and reviewed by supervisors for all grant payroll costs charged during the award year and were provided to the auditors. A new process is in place for quarterly certifications to follow 2CFR 200.430(i). The required corrective action for Finding 2023-001 for the period 07/01/2022 – 06/30/2023 was completed in December 2023. The person now responsible for completion of the corrective action plan is Dennis James, Chief Financial Officer.

View Audit 301814

Finding 391189 (2023-003)

Significant Deficiency 2023

City and Borough of Juneau, Alaska

AK

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

Finding: 2023-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Reporting (Bartlett Regional Hospital enterprise fund) Name of Contact Person: Joe Wanner, Chief Financial Officer Corrective Action: For any unusual or new grant reporting, management will implement add...

Finding: 2023-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Reporting (Bartlett Regional Hospital enterprise fund) Name of Contact Person: Joe Wanner, Chief Financial Officer Corrective Action: For any unusual or new grant reporting, management will implement additional review procedures to ensure information is captured as expected. The unallowable expense, which had previously been reported and was mistakenly included in the report again, will be “replaced” by unreimbursed lost revenues, which was the intended use of the funds from the beginning. Proposed Completion Date: March 26, 2024

View Audit 301806 Questioned Costs: $1

Finding 391170 (2023-003)

Material Weakness 2023

Mercy Health

MO

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.333 § 200.403

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansa...

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Views of Responsible Officials and Planned Corrective Actions: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will implement testing of our inventory system (Lawson) to ensure calculations are accurate. All review and approvals of capital equipment will be maintained in Strata. Responsible Party: Jill McCart, VP Accounting and Reporting Date of Completion: By 6/30/24

View Audit 301777 Questioned Costs: $1

Finding 391168 (2023-001)

Material Weakness 2023

Mercy Health

MO

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

Finding 2023-001 Activities Allowed or Unallowed Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (AR...

Finding 2023-001 Activities Allowed or Unallowed Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (“PRF”) Award Period of Performance: 01/01/2020–12/31/2022 (Period 4) and 01/01/2020–06/30/2023 (Period 5) Condition: Management performed a duplication of benefits analysis to ensure expenses to be used to substantiate PRF funding received were not reimbursed or obligated to be reimbursed by another source. The methodology included the development of estimated cost reimbursement rates by location that was applied to the PRF expenditures. During our allowable costs testing of expenditures, we noted errors in the duplication of benefits analysis and/or misapplication of the estimated cost reimbursement rates which resulted in a net overstatement of expenses totaling $2,078,408. In addition, we noted instances where employees’ hours reported on the timecards for substantiation of funding for the federal program were not consistently evidenced as reviewed and approved. Views of Responsible Officials and Planned Corrective Actions: While we overstated the expenses submitted totaling $2.1 million, this was an oversight during our review process. There are additional expenditures available in excess of funding received; therefore, we believe we have incurred either lost revenues or expenditures in excess of funding received. We will perform additional review of expenditures including the duplication of benefits analysis and application of the cost reimbursement rates to ensure appropriate amounts are used for PRF funding and ensure compliance with the terms of the agreement. Mercy Health’s Finance team will continue to stress the importance of timecard approval to leadership. Responsible Party: Jill McCart, VP Accounting and Reporting Date of Completion: By 6/30/24

View Audit 301777 Questioned Costs: $1

Finding 391125 (2023-012)

Significant Deficiency 2023

State of Iowa

IA

Allowable Costs / Cost Principles Student Financial Aid

The Department will retrain staff on when an overpayment is needed, when to cancel a case and what to look for in the system when an alert is received about a child entering foster care. A reminder will be provided to all Income Maintenance staff providing the policies and procedures for duplicate ...

The Department will retrain staff on when an overpayment is needed, when to cancel a case and what to look for in the system when an alert is received about a child entering foster care. A reminder will be provided to all Income Maintenance staff providing the policies and procedures for duplicate benefits. This reminder will be emailed and also discussed at team staff meetings.

View Audit 301710

Finding 391124 (2023-011)

Material Weakness 2023

State of Iowa

IA

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

The Department will work with the U.S. Department of Education to identify appropriate steps for resolution. In addition, Department leadership directed ESEA and federal grants management training for the Bureau of Federal Programs and all other relevant department staff, which will provided by the...

The Department will work with the U.S. Department of Education to identify appropriate steps for resolution. In addition, Department leadership directed ESEA and federal grants management training for the Bureau of Federal Programs and all other relevant department staff, which will provided by the Council for Chief State Schools Officer’s Federal Education Group beginning in April of 2024.

View Audit 301710 Questioned Costs: $1

Finding 391107 (2023-002)

Significant Deficiency 2023

State of Iowa

IA

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

The Department will review allocable rates during the time frame to determine if corrective disbursement entries are needed to their respective program codes. The Department began the process in October 2023. The Department will also revise, and update policies and procedures related to allocable c...

The Department will review allocable rates during the time frame to determine if corrective disbursement entries are needed to their respective program codes. The Department began the process in October 2023. The Department will also revise, and update policies and procedures related to allocable costs based on time entries.

View Audit 301710

Finding 391105 (2023-001)

Significant Deficiency 2023

State of Iowa

IA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Reporting

The Department has implemented a payroll policy and procedure, that requires staff to enter a work reporting code for time worked and addresses timelines in which correcting entries must be completed. The Department will review all pay periods during the time frame to determine if corrective disburs...

The Department has implemented a payroll policy and procedure, that requires staff to enter a work reporting code for time worked and addresses timelines in which correcting entries must be completed. The Department will review all pay periods during the time frame to determine if corrective disbursement entries need to be made to properly allocate actual time reported to their respective program codes. The Department began the process in October 2023.

View Audit 301710

Finding 391099 (2023-006)

Significant Deficiency 2023

Avera Health

SD

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

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Activities Allowed and Allowable Costs Significant Deficiency in Internal Control over Compliance Finding Summary: Our testing over a...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Activities Allowed and Allowable Costs Significant Deficiency in Internal Control over Compliance Finding Summary: Our testing over activities allowed and allowable costs identified four instances where the supporting documentation did not agree with the expenditures claimed in the expenditure listing for the program. Responsible Individuals: Jamie Schaefer, John Neth Corrective Action Plan: The Organization will review and strengthen the controls surrounding the period of performance and activities allowed and allowable costs. There are no questioned costs related to this finding. The Organization is in the process of implementing a new enterprise resource planning software which will include a grant module. The grant module will have automated controls surrounding period of performance evaluation and costs will be drillable to ensure cost claimed and supporting documentation exact alignment. Anticipated Completion Date: October 1, 2024

View Audit 301691

Corrective Action Plans

Filters