Corrective Action Plans

Finding 390729 (2023-003)

None 2023

WV

Allowable Costs / Cost Principles HUD Housing Programs Reporting

#2303-003 Reporting of Time and Effort US Department of Education Title I Grants to Local Educational Agencies AL#84.010 ...

#2303-003 Reporting of Time and Effort US Department of Education Title I Grants to Local Educational Agencies AL#84.010 Recommendation: We recommend that the Clay County Board of Education's Title I Department implement procedures to accurately document and maintain the "Time and Effort" Documentation of all employees funded with federal funding, as required. Action Taken: The Title I Department of the Clay County Board of Education will implement procedures to ensure that "Time and Effort" Documentation and records are adequately maintained, as required for all applicable employees. Jennifer R. Paxton, CPA/Treasurer, and the Title I Director are responsible for implementing these procedures immediately.

View Audit 301414

Finding 390713 (2023-003)

Significant Deficiency 2023

Housing Authority of the City of Hope

AR

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Condition and Criteria: Expenses charged to the program should be specific to the operating expenses of the program. Allocation of payroll and related benefits were cited as a concern in the CMR. As a result, costs may not be properly allocated across all programs correctly.Auditor’s Recommendati...

Condition and Criteria: Expenses charged to the program should be specific to the operating expenses of the program. Allocation of payroll and related benefits were cited as a concern in the CMR. As a result, costs may not be properly allocated across all programs correctly.Auditor’s Recommendation: Documentation of expenses and the related procurement should be maintained and accessible for review. In addition, the cost allocation of expenses across programs should be reviewed. Grantee Response: After the end of the fiscal year, we reviewed the allocation of salaries and benefits among programs and provided a journal entry to be recorded as part of the audit adjustments. Anticipated Completion Date: June 30, 2024

View Audit 301395

Finding 390693 (2023-010)

Material Weakness 2023

Wabash City Schools

IN

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

FINDING 2023-010 Finding Subject: ESSER (Education Stabilization Fund) – Allowable Activities, Allowable Costs/Cost Principles Federal Programs: Education Stabilization Fund Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the S...

FINDING 2023-010 Finding Subject: ESSER (Education Stabilization Fund) – Allowable Activities, Allowable Costs/Cost Principles Federal Programs: Education Stabilization Fund Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed and Allowable Costs/Cost Principles compliance requirement. The School Corporation did not have internal controls in place over payroll disbursements. A detailed report of payroll disbursements paid without evidence of review and approval by a knowledgeable person. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Develop process and procedures for verifying payroll disbursements from grant funds. On a monthly basis, Payroll coordinator will print payroll disbursements from federal grant funds to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024

View Audit 301362

Finding 390690 (2023-009)

Material Weakness 2023

Wabash City Schools

IN

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

FINDING 2023-009 Finding Subject: Special Education Cluster - Earmarking Summary of Finding: The School Corporation is a member of the Wabash Miami Area Programs for Exceptional Children (Cooperative). During fiscal year 2021-2022 and 2022-2023, the Cooperative operated the special education program...

FINDING 2023-009 Finding Subject: Special Education Cluster - Earmarking Summary of Finding: The School Corporation is a member of the Wabash Miami Area Programs for Exceptional Children (Cooperative). During fiscal year 2021-2022 and 2022-2023, the Cooperative operated the special education programs and spent the federal money on behalf of all its members. As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Matching Level of Effort, Earmarking compliance requirement. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the earmarking requirements. The Cooperative did not have adequate procedures in place to ensure that the required level of expenditures for non-public school students with disabilities was met for each member school. The Cooperative did not have effective internal controls to ensure non-public school expenditures were appropriately identified and reported. The Non-Public Proportionate Share expenditures for the 20611-054-PN01, 20619-054-PN01, 21611- 054-PN01 and 21619-054-PN01 grant awards could not be verified for the individual member schools. The non-public school share funds for all member schools were comingled and the aggregate amount of expenditures was then allocated to the member schools on a percentage basis. These allocations were the amounts reported to IDOE. As such, we were unable to identify which expenditures were for each school in order to verify the minimum amount per the grant award was expended and properly reported to IDOE as required. The lack of internal controls and noncompliance were isolated to the 20611-054-PN01, 20619-054- PN01, 21611-054-PN01 and 21619-054-PN01 grant awards. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: The district will collaborate with the SPED co-op to implement controls to ensure compliance with earmarking requirements. Anticipated Completion Date: To be completed by July 2024

View Audit 301362

Finding 390682 (2023-006)

Material Weakness 2023

Wabash City Schools

IN

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

FINDING 2023-006 Finding Subject: Special Education Cluster - Activities Allowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure ...

FINDING 2023-006 Finding Subject: Special Education Cluster - Activities Allowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The School Corporation did not have internal controls in place over payroll disbursements. A detailed report of payroll disbursements was paid without evidence of review and approval by a knowledgeable person. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Develop process and procedures for verifying disbursements from grant funds. On a monthly basis, Corporation Treasure will print expenditure report from federal grant funds to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024

View Audit 301362

Finding 390676 (2023-005)

Material Weakness 2023

Wabash City Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Special Tests & Provisions: School Food Service Accounts Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would li...

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Special Tests & Provisions: School Food Service Accounts Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance for Special Tests & Provisions: School Food Service Accounts. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: On a monthly basis, Corporation Treasure will print receipt postings to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024

View Audit 301362

Finding 390664 (2023-003)

Material Weakness 2023

Wabash City Schools

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.302 § 200.303 § 200.439

FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Allowable Activities and Allowable Costs Summary of Finding: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective...

FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Allowable Activities and Allowable Costs Summary of Finding: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting noncompliance related to allowable activities and allowable costs. The School Corporation purchased two pieces of equipment that were over $5,000 each in Fiscal Year 2023 without approval from the Federal awarding agency or pass-through entity. The first piece of equipment was a liftgate in the amount of $6,906, and the second piece of equipment was a vehicle in the amount of $7,500 for a combined total of $14,406. The financial management system of each non-federal entity must provide written procedures for determining allowability of costs in accordance with the federal regulations and the terms and conditions of the Federal Award. The policy should provide clear guidance as to what costs constitute appropriate direct and indirect charges to federal awards as well as provide for consistency in charging practices across the School Corporation. The School Corporation did not have an allowable costs policy outlining the School Corporation's processes and policies with regards to costs charged to federal grants. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Retrain Food Service Director and Assistant Food Service Director on the process for purchasing equipment. The district will also develop and pass an Allowable Costs Policy. Anticipated Completion Date: To be completed by July 1, 2024

View Audit 301362 Questioned Costs: $1

Finding 390648 (2023-224)

Material Weakness 2023

State of Idaho

ID

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

Finding Number 2023-224: The required audited financial reports were not collected as required to ensure compliance with the Managed Care Organization contracts. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical A...

Finding Number 2023-224: The required audited financial reports were not collected as required to ensure compliance with the Managed Care Organization contracts. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Division will amend all current managed care contracts to include the requirement to submit an audited financial report annually. This contract language will also be incorporated into all future Medicaid managed care procurements. The Division will also review and confirm all required contract elements outlined in 42 CFR 438.3 are clearly outlined in Medicaid managed care contracts. Lastly, the Division intends to coordinate with the Department of Insurance to learn more about their review process of audited financial statements and determine if there is an opportunity to coordinate oversight efforts for Medicaid managed care contracts going forward. Anticipated Corrective Action Date: September 2024 Responsible for Corrective Action: Juliet Charron, Division Administrator Juliet.Charron@dhw.idaho.gov 208-364-1831 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390644 (2023-223)

Significant Deficiency 2023

State of Idaho

ID

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

Finding Number 2023-223: Managed Care providers lacked documentation to support continued eligibility within the Medicaid Program. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to P...

Finding Number 2023-223: Managed Care providers lacked documentation to support continued eligibility within the Medicaid Program. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The 21st Century Cures Act requires all states to enroll both fee-for-service and managed care providers. Idaho Medicaid is currently out of compliance with this requirement for most of the providers within managed care contractor networks. The state is also working to come into compliance with a requirement in the Affordable Care Act to revalidate all enrolled providers at least every 5 years. The Division has begun the systems work necessary to come into compliance with both of these requirements and anticipates working through enrollment and revalidation activities into CY2025. Once completed, the Division will have an accurate and complete provider file that will be shared with contracted managed care plans to support their contracting efforts. Any providers who contract with the managed care plans will be required to be fully enrolled and credentialed with Idaho Medicaid before rendering services and billing. Pursuant to the Consolidated Appropriations Act of 2023, states are required by July 2025 to have a searchable and regularly updated provider directory for both managed care plans and fee-for-service programs. Idaho Medicaid is working to develop processes to validate directories and ensure that providers are providing updates to their information as necessary. Through this effort, Idaho Medicaid will further bolster internal processes and controls to ensure accurate provider network information is shared with Medicaid participants and maintained within our systems. Anticipated Corrective Action Date: July 2025 Responsible for Corrective Action: Juliet Charron, Division Administrator Juliet.Charron@dhw.idaho.gov 208-364-1831 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390638 (2023-217)

Material Weakness 2023

State of Idaho

ID

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Student Financial Aid § 200.303

Finding Number 2023-217: The Department does not have documented internal controls for adjustments processed to the Foster Care -Title IV—E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Office agrees with this finding. Corrective Act...

Finding Number 2023-217: The Department does not have documented internal controls for adjustments processed to the Foster Care -Title IV—E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Office agrees with this finding. Corrective Action: The Department will continue to record adjustment activity through Help Desk tickets, SharePoint documentation, and ESPI. The Department will ensure improved visibility to the adjustment and approval process and documentation by ensuring all roles who need access (including auditors), have access to all relevant systems and storage locations such as access to SharePoint and Help Desk tickets. This step will be completed by April 30, 2024. Anticipated Corrective Action Date: April 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390637 (2023-216)

Material Weakness 2023

State of Idaho

ID

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

Finding Number 2023-216: The Department did not have appropriate documentation to support allowability of transactions for the Foster Care Title IV-E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. ...

Finding Number 2023-216: The Department did not have appropriate documentation to support allowability of transactions for the Foster Care Title IV-E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: A new feature was added to ESPI on 1/9/24 to record the reason (purpose) for certain service types, including transportation. The system is programmed to disallow Title IV-E if the reason listed does not meet IV-E eligibility criteria (see image below). An additional control will be added to the system to have the same control procedure used for a medical service type and education service type. Further development is underway for additional control procedures and should be completed by April of 2025. P-card transactions do not process through ESPI. Quarterly reports will be obtained to review any P-card transactions that utilized Title IV-E to confirm appropriate documentation is on record. This will be completed by April 30, 2024. Anticipated Corrective Action Date: April 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345 Questioned Costs: $1

Finding 390630 (2023-213)

Material Weakness 2023

State of Idaho

ID

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.1 § 200.303 § 200.331 § 200.332 § 200.414

Finding Number 2023-213: The Department erroneously determined that two recipients of Temporary Assistance for Needy Families (TANF) funding were contractors instead of subrecipients resulting in noncompliance with the subrecipient monitoring requirements. Federal Programs: 93.558 – Temporary Ass...

Finding Number 2023-213: The Department erroneously determined that two recipients of Temporary Assistance for Needy Families (TANF) funding were contractors instead of subrecipients resulting in noncompliance with the subrecipient monitoring requirements. Federal Programs: 93.558 – Temporary Assistance for Needy Families Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Department has revised our training of personnel involved in subrecipient and contractor determinations. These contract managers and monitors completed grant training on March 12th-13th, 2024 which included sections about subrecipient and contractor determinations, risk assessment and documentation. All newly hired employees will be trained beginning April 2024 with an on-line module. For the impacted vendor, an updated Risk Assessment was completed and submitted to LSO. Additionally, the Department has started the work to effectively change the designation of the vendor and ensure all required information is provided to this subrecipient. This process will be completed by April 30th, 2024. The Department will develop internal control procedures to ensure all required information is provided to the subrecipients at the time of the subawards. These updated internal control procedures will be completed by June 30th, 2024. Anticipated Corrective Action Date: June 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390629 (2023-212)

Material Weakness 2023

State of Idaho

ID

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

Finding Number 2023-212: The review of the Low-Income Home Energy Assistance Program (LIHEAP) earmarking compliance requirements was not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. ...

Finding Number 2023-212: The review of the Low-Income Home Energy Assistance Program (LIHEAP) earmarking compliance requirements was not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Program will document the current process regarding the preparation, review, and approval of the Low-Income Home Energy Assistance Program (LIHEAP) budget that includes maintaining the documentation of the earmarking reviews that are being completed. The program will prepare the Low-Income Home Energy Assistance Program (LIHEAP) budget. This budget will be submitted to the Bureau Chief, as a second review of accuracy and compliance, to include review of earmarking limits, prior to routing the Annual State Plan for review and submittal or the allocation of any funding. Documentation will be maintained to support the review and approval. Anticipated Corrective Action Date: The Program will write a process document to support this corrective action and will implement this process prior to the start of the new LIHEAP season beginning 10/1/2024. Program will have a process document in place by 9/30/24. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390628 (2023-211)

Significant Deficiency 2023

State of Idaho

ID

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

Finding Number 2023-211: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees wit...

Finding Number 2023-211: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: Testing of the updated benefits matrix will be completed by the Program annually, and the results will be documented using an established scenario testing script. Results of the testing will be documented and submitted to the Bureau Chief, as a second review of accuracy and compliance, prior to moving the updated matrix into the production environment. Documentation will be maintained to support the review and approval. Anticipated Corrective Action Date: The Program will write a process document to support this corrective action and will implement this process prior to the start of the new LIHEAP season beginning 10/1/2024. Program will have a process document in place by 9/30/24. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390627 (2023-210)

Material Weakness 2023

State of Idaho

ID

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

Finding Number 2023-210: Low-Income Home Energy Assistance Program (LIHEAP) performance and special reports did not include a review for accuracy and compliance prior to submission. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Depar...

Finding Number 2023-210: Low-Income Home Energy Assistance Program (LIHEAP) performance and special reports did not include a review for accuracy and compliance prior to submission. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Program will develop a process to work with the Information Management and Analysis Team (IMAT) within the division to compile the data for the Low-Income Home Energy Assistance Program (LIHEAP) reports. Program will review the completed reports for accuracy. All reports will then be submitted to the Bureau Chief, as a second review of accuracy, prior to submission to Federal Partners. Documentation will be maintained to support the preparation, review, and approval steps. The process outlines a timeline to have reports prepared and reviewed ahead of the established deadline. Program will communicate with our Federal Partner if circumstances arise that would prevent a report from being submitted by an established deadline to receive an extension. Anticipated Corrective Action Date: The Program has already implemented the involvement of IMAT and secondary review and approval processes. Program will write a process document to support the corrective action. The documented process will be in place by April 15th, 2024. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390612 (2023-209)

Significant Deficiency 2023

State of Idaho

ID

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.416

Finding Number 2023-209: Monthly cost allocation statistics, used to allocate indirect costs to federal grants, were not reviewed and approved by the Department. Federal Programs: 10.551 - Supplemental Nutrition Assistance Program (SNAP) 10.561 - State Administrative Matching Grants for the Suppl...

Finding Number 2023-209: Monthly cost allocation statistics, used to allocate indirect costs to federal grants, were not reviewed and approved by the Department. Federal Programs: 10.551 - Supplemental Nutrition Assistance Program (SNAP) 10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (SNAP) 21.027 - Coronavirus State and Local Fiscal Recovery Funds 93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises 93.558 - Temporary Assistance for Needy Families (TANF) 93.568 - Low-Income Home Energy Assistance 93.569 – Adoption Assistance 93.575 - Child Care and Development Block Grant (CCDF 93.658 - Foster Care Title IV-E 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.778 - Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: With the implementation of Luma and the interfaced cost allocation module, finance has spent a significant amount of time assessing the best practices for cost allocation processing steps. Since going live on 7/1/23, each month, finance has reviewed, revised, and refined process steps. The department’s budget analysts who hold oversight of some cost allocation processes, use a spreadsheet to track processing. Finance has added a step in the process to ensure that finance reviews the cost allocation SharePoint site for review and signature of each supervisor responsible for each statistic. Anticipated Corrective Action Date: March 1, 2024 Responsible for Corrective Action: Staci Phelan, Division Administrator Staci.Phelan@dhw.idaho.gov 208-334-0632 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

View Audit 301345

Finding 390597 (2023-206)

Significant Deficiency 2023

State of Idaho

ID

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.332

Finding Number 2023-206: The Department did not fully disclose required information to subrecipients, document subrecipient risk assessments, or ensure subrecipient audits were received for the Coronavirus State and Local Fiscal Recovery Fund. Federal Programs: 21.027 – Coronavirus State and Local ...

Finding Number 2023-206: The Department did not fully disclose required information to subrecipients, document subrecipient risk assessments, or ensure subrecipient audits were received for the Coronavirus State and Local Fiscal Recovery Fund. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The department agrees with the lack of certain required subrecipient information datapoints for the CSLFRF projects. • The department had an imperfect implementation of the initial subawards for CSLFRF documentation for subrecipients. Our general practice includes providing the identified federal award identification datapoints; however, this was not the case with the initial CSLFRF subrecipients. As an example, the period of performance was truncated to ensure that we were able to meet the aggressive timeline outlined in the American Rescue Plan Act; we will include both the true period of performance as set forth in the grant and the budgetary period in which the subrecipient will need to complete their work. Carrie Champlin, Contracts Manager, and Rob Sepich, Chief Financial Officer will implement these changes by April 15, 2024. • The department had processes for evaluating the risk of subrecipients, however it could be improved and made clearer for auditors and we will implement a process used by other agencies to memorialize the risk factors outside of email in a clear and concise manner. Additionally, the department is currently implementing a new software system, Amplifund, to aid in registering subrecipients, monitoring them, and closing out subawards. This system will include all of the relevant information necessary for both the subrecipient and the department in one location and will provide consistency across the department. Amplifund implementation is currently underway and will be used department- wide by August 2024. Doug McRoberts, Grants Manager, Jeri Ann Fogg, Accounting Manager, Carrie Champlin, Contracts Manager are working on the integration of Amplifund. Anticipated Corrective Action Date: April 15, 2024 Responsible for Corrective Action: Rob Sepich, Chief Financial Officer Rob.Sepich@deq.idaho.gov 208-373-0292

View Audit 301345

Finding 390548 (2023-002)

Material Weakness 2023

Turning Point of Central California, Inc.

CA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Material Weakness § 200.118 § 200.318 § 200.326

Finding 2023-002 Procurement Corrective Action: TPOCC has updated its Finance Manual, inclusive of a procurement policy in compliance with Uniform Guidance (2 CFR Part 200). We have also had all management staff who deal with programs funded by Federal Funds attend training on Uniform Guidance. We w...

Finding 2023-002 Procurement Corrective Action: TPOCC has updated its Finance Manual, inclusive of a procurement policy in compliance with Uniform Guidance (2 CFR Part 200). We have also had all management staff who deal with programs funded by Federal Funds attend training on Uniform Guidance. We will continue to have staff attend these training courses to ensure that they are familiar with the requirements of Uniform Guidance. We have also begun implementing a procurement system (Pairsoft Paramount Workplace) and anticipate a go live of April 1st, 2024. This will help ensure our procurement policies are implemented and followed uniformly. Person Responsible: Finance Director, Lacy Meneses and CFO, Will Goodall Timing for Implementation: Currently in progress and procurement software will Go Live on April 1st, 2024. Document ID: b51a2bdf940fc8367245121fabb689a6083edd8e9deb8925c16c8fec9313f6b8 Page 1 Summary Schedule of Prior Year Findings and Questioned Costs Turning Point of Central California, Inc. did not retain procurement records to support its assertion that it is contracting with vendors that provide the best prices. Turning Point of Central California, Inc. has not updated its procurement policy to comply with the Uniform Guidance (2 CFR Part 200). This finding was first reported in the June 30, 2021 audit, issued in June 2022, and Turning Point of Central California, Inc. did not have adequate time to implement its corrective action plan during the year ended June 30, 2023. Questioned Costs: None

View Audit 301300

Finding 390534 (2023-001)

Significant Deficiency 2023

Jacobs & Cushman San Diego Food Bank

CA

Questioned Costs Allowable Costs / Cost Principles

The Food Bank is aware of the issue brought to them by external auditors during the expense testing phase of the audit for the fiscal year ended June 30, 2023. The issue under review is that the indirect payroll costs did not follow the cost allocation plan for three quarters of the fiscal year. Sta...

The Food Bank is aware of the issue brought to them by external auditors during the expense testing phase of the audit for the fiscal year ended June 30, 2023. The issue under review is that the indirect payroll costs did not follow the cost allocation plan for three quarters of the fiscal year. Staff turnover within the finance department during the period contributed to this error. To avoid this error going forward, the Food Bank has filled open positions so that the department is fully staffed and has brought on a Chief Financial Officer. In addition, processes have been set in place for managerial review of allocations on a quarterly basis. Actions to correct the finding have been completed. For inquiries regarding this finding, please contact Allyson Tutor, CFO at 858-863-5114 who is responsible for the corrective action.

View Audit 301284 Questioned Costs: $1

Finding 390533 (2023-009)

Material Weakness 2023

Success Center San Francisco

CA

Questioned Costs Allowable Costs / Cost Principles

Response: CES subtracted previous Supportive Services costs that were not allowable in the December 31, 2023 quarterly report. CES has attached the supporting documentation that supports the correction of Supportive Services costs. CES reviewed the GPMS YB Participants Status and Contact Report, at...

Response: CES subtracted previous Supportive Services costs that were not allowable in the December 31, 2023 quarterly report. CES has attached the supporting documentation that supports the correction of Supportive Services costs. CES reviewed the GPMS YB Participants Status and Contact Report, attached in Appendix H, and compared the list to all the Participant on the books and removed any participant direct costs with attached Journal Entry, Appendix I.

View Audit 301283 Questioned Costs: $1

Finding 390518 (2023-001)

Significant Deficiency 2023

Community Action Partnership of Mercer County

PA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.403

March 27, 2024 Federal Audit Clearinghouse Re: Corrective Action Plan for Community Action Partnership of Mercer County To whom it may concern: Views of Responsible Officials and Planned Corrective Actions: 2023-01 There is no disagreement with the audit finding regarding costs allowed or allow...

March 27, 2024 Federal Audit Clearinghouse Re: Corrective Action Plan for Community Action Partnership of Mercer County To whom it may concern: Views of Responsible Officials and Planned Corrective Actions: 2023-01 There is no disagreement with the audit finding regarding costs allowed or allowable reviewed. The Organization’s fiscal policy manual policies and procedures states Audit costs are direct charged to each program and are billed separately to each program at a cost of 2% of the total budget of the program or grant. This policy has been enforced for years with an agreement between auditors and the organization. Management will review and update the Organization’s fiscal policy manual and procedures for consistency and compliance with GAAP and Uniform Guidance. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: May 31, 2024 Respectfully Submitted, Michelle Clarke VP/CFO

View Audit 301273 Questioned Costs: $1

Finding 390473 (2023-002)

Material Weakness 2023

Guthrie County Hospital

IA

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Department of Health and Human Services: Federal Financial Assistance Listing #93.498 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN #426037759 Activities Allowed or Unallowed and Allowable Costs/Cost Principles ...

Department of Health and Human Services: Federal Financial Assistance Listing #93.498 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN #426037759 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control Over Compliance Criteria: 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. Condition: Guthrie County Hospital (the Hospital) reported expenses in the Department of Health and Human Services (HHS) special report for Period 4 that were not reduced by reimbursement from other sources or that other sources were obligated to reimburse. Additionally, the Hospital did not report its excess expenses as unreimbursed expenses attributable to Coronavirus in the HHS special report, did not report total interest earned on the ARP Rural Payments and Period 4 General Distribution Payments, and reported gross revenues/net charges from patient care by quarter for 2021 when net revenues should have been reported. In addition, there was no evidence retained that the HHS special report was reviewed by an individual separate from the preparer prior to submission. Planned Corrective Action: Management will implement an internal control policy for federal awards compliance to more diligently review the reporting of expenses and revenues to ensure all reporting requirements are met. However, had the errors in reporting of expenses and lost revenues been identified and corrected prior to reporting, the Hospital would have demonstrated that they had incurred eligible expenses and lost revenue in excess of the Period 4 funds received, including interest on such funds. Contact Person, Title and Phone Number: Christopher Stipe, Chief Executive Officer, (641)332-2201 Anticipated Date of Completion: June 30, 2024

View Audit 301254

Finding 390470 (2023-003)

Material Weakness 2023

The Be Kind People Project Foundation

AZ

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

2023‐003 Material Weakness in Internal Control over Compliance with Actvities Allowed Unallowed and Allowable Costs/Cost Principles Condition: The Organiza􀆟on did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing av...

2023‐003 Material Weakness in Internal Control over Compliance with Actvities Allowed Unallowed and Allowable Costs/Cost Principles Condition: The Organiza􀆟on did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing available. Management’s Response and Corrective Action Plan: The CEO will add a regular discussion point to the weekly finance meetings in which the finance department reports on both the status of federal funds and the expenditures using those funds. Responsible Individuals: -Maintain separate tracking account – Marcia Meyer, CEO, in conjunction with Board Finance Committee - Authorization for use of funds – Marcia Meyer - Maintenance of records for use – Jennie Myers - Confirmation with use of funds per allowable uses per national guidelines – Jennie Myers - Reporting on monthly finance report – Jennie Myers Anticipated Completion Date: This process is underway and will be visible at the fiscal year‐end audit in June 2024

View Audit 301253

Finding 390401 (2023-002)

Significant Deficiency 2023

Livingstone College

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Finding 2023-002 – U.S. Department of Education (USDE), Title IV Student Financial Aid Programs (Deficiency): We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs a) One (1) out of six (6) stu...

Finding 2023-002 – U.S. Department of Education (USDE), Title IV Student Financial Aid Programs (Deficiency): We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs a) One (1) out of six (6) students tested for R2T4 did not have Title IV funds returned to the Federal government within the required 45 days. Title IV HEA 34 CFR 668.22. b) The College was not reconciling between Financial Aid and Business Office on the monthly basis per SFA Handbook Ch. 5 CFR668.161-668.176. Auditor’s Recommendation – We recommend that the College ensure adequate documentation is obtained and kept on file as evidence that all expenditures meet allowable cost and other requirements under the grant program. Corrective Action – Management agrees with this finding. The College will place additional emphasis on the R2T4 of funds. Management is reviewing the timing of presentation of situations to Financial Aid that require returning funds to the Department. Additional focus will be placed on procedures to timely report withdraws to Financial Aid to support returned funds in the required 45 days. In addition, the College prepares monthly reconciliations between Financial Aid and the Business Office, but often delayed in completion. Going forward, the reconciliation will be noted on the monthly closing list and requires both the Assistant Vice President of Financial Aid and Controller to sign and date the reconciliation to demonstrate compliance with the monthly requirement.

View Audit 301203

Finding 390378 (2023-103)

Material Weakness 2023

Coconino County

AZ

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

Cluster name: WIOA Cluster Assistance Listings number and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated complet...

Cluster name: WIOA Cluster Assistance Listings number and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completion date: June 30, 2024 Concur. The County Administration Department acknowledges the work experience (WEX) requirement was not met for the Workforce Innovation and Opportunity Act (WIOA) Youth Program Year 2021 allocation. The Department has a tracking mechanism in the financial system and other records to account for the percentage of youth expenditures made on WEX activities. Due to an oversight, the percentage of WEX expenditures in relation to the total allocation was not monitored by staff. Additionally, the amount of WEX funding allocated to the Youth program service provider was insufficient to meet the requirement. The Department will write procedures for the monitoring of earmarking requirements, including WEX, to ensure the roles and responsibilities of staff and key stakeholders are clearly defined. The calculation of funds allocated to the service provider will factor in the level of WEX expenditures needed for the County to meet the requirement. The Department will work with the WIOA Youth program service provider to employ best practices and strategies to recruit eligible in-school and out-of-school youth in need of WEX activities to further their skills and job readiness. The Department will monitor WEX expenditures made by the service provider and provide technical assistance as needed. If the Department projects the County will not meet the threshold for a certain program year allocation, it will seek technical assistance from the Arizona Department of Economic Security.

View Audit 301196 Questioned Costs: $1

Corrective Action Plans

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