Corrective Action Plans

Finding 553484 (2024-002)

None 2024

CA

Questioned Costs Allowable Costs / Cost Principles

Management’s Views and Corrective Action Plan Management response to finding 2024-002: Unallowable costs over the NIH salary cap Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Alzheimer's Clinical Trial Consortium Award Number: ...

Management’s Views and Corrective Action Plan Management response to finding 2024-002: Unallowable costs over the NIH salary cap Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Alzheimer's Clinical Trial Consortium Award Number: 5U24AG057437-07 Award Years: 2023-2025 Assistance Listing Title: Aging Research Assistance Listing Number: 93.866 Pass-through entities: Not applicable As described in finding 2024-002, the process for manually creating sub-grants within our financial systems required an attribute to be activated. In this instance the attribute in question was not activated, resulting in the NIH salary cap restriction not to be enforced within the payroll system. In November 2024, when this instance was identified, a correction was immediately made to stop any future amounts above the salary cap to be charged to the award and to avoid any further errors. To ensure any transactions that occurred while the incorrect system attribute was in place were properly addressed, corrective measures in the form of cost transfers were made during this period by the department to minimize inappropriate charges to the sponsor. As part of the university’s corrective action plan, the Sponsored Project Accounting (SPA) office has completed a full review of all awards and determined this to be an isolated event. As of March 2025, to further strengthen internal controls over compliance, the SPA office has implemented a revised approach for the creation of new manual sub-grants which will ensure the necessary NIH salary cap restrictions are applied. Additionally, training documents have been updated to reflect this revised approach, and all SPA staff have now received training on this new update. Contact Person: Cindy Lee, Director, Sponsored Projects Accounting, cmlee@usc.edu

View Audit 352166 Questioned Costs: $1

Finding 553469 (2024-002)

Material Weakness 2024

The Howard University

DC

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Name of Responsible Individual: Rawle Howard, Assistant Vice President, Procurement Corrective Action: Accounts Payable (AP) will create a Corrective Action plan to include the following. 1. The process to review Payment Request Forms (“PRFs”), used for payment to vendors that do not require the u...

Name of Responsible Individual: Rawle Howard, Assistant Vice President, Procurement Corrective Action: Accounts Payable (AP) will create a Corrective Action plan to include the following. 1. The process to review Payment Request Forms (“PRFs”), used for payment to vendors that do not require the use of a purchase order, will be improved by requiring the review of supporting documents to ensure expenses are allowable by the newly established Sponsored Program Office (SPO) post award team. This team will thoroughly review supporting documents to ensure expenses are allowable, allocable, and reasonable according to University policies and grant terms. PRFs will be reviewed by SPO and Grants and Contracts Accounting (GCA) and will serve as the key control point before transactions are forwarded to accounting to post to sponsored awards. 2. AP is working with Enterprise Technology Services (ETS) to modify the Workday Ad Hoc Business process to require additional review by PI, SPO, and GCA before payments can be issued. Each approval role will receive guidance regarding 3. AP will collaborate with SPO and GCA to issue communications and provide training to all PIs, SPO, GCA, and AP personnel. Anticipated Completion Date: December 31, 2025

View Audit 352153 Questioned Costs: $1

Finding 553086 (2024-013)

Significant Deficiency 2024

The Howard University

DC

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.305

Name of Responsible Individual: Marchon Jackson, Associate Vice President of Research; Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations; Rawle Howard, Assistant Vice President, Procurement Corrective Action: The process to review subrecipient invoices will be improved b...

Name of Responsible Individual: Marchon Jackson, Associate Vice President of Research; Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations; Rawle Howard, Assistant Vice President, Procurement Corrective Action: The process to review subrecipient invoices will be improved by requiring the review of supporting documents to ensure expenses are allowable by the Sponsored Program Office (SPO) post award team. This team will thoroughly review supporting documents to ensure expenses are allowable, allocable, reasonable and recorded in the proper period according to university policies and grant terms. Invoices will be reviewed by SPO and will serve as the key control point before transactions are forwarded to accounting to post to sponsored awards. Subrecipient invoices will be paid by Accounts Payable only after approval by SPO and GCA. The Director of Compliance will conduct spot checks on all sponsored transactional activity, especially for high-risk grants to provide an additional layer of oversight. The new review process and training for these responsibilities will be implemented by spring 2025 as part of the broader campus-wide workflow training and staffing up of the new SPO Post-Award office. Anticipated Completion Date: June 30, 2025

View Audit 352153

Finding 552703 (2024-012)

Significant Deficiency 2024

The Howard University

DC

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting § 200.430

Name of Responsible Individual: Marchon Jackson, Associate Vice President for Research, Brenda Willis, Senior Executive Director of Financial Grants & Contracts, Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations Corrective Action: A new office is being developed to addres...

Name of Responsible Individual: Marchon Jackson, Associate Vice President for Research, Brenda Willis, Senior Executive Director of Financial Grants & Contracts, Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations Corrective Action: A new office is being developed to address the timeliness of the personnel payment request forms. In Phase I, CRAs will be assigned to high-volume research colleges to provide support for costing allocations. Phase 2 will encompass existing departmental administrators who will gradually transition into more centralized research workflows supported by CRAs. A shared services model for the remaining colleges is planned for FY26. Quarterly checklist and updates outlining cost allocation statuses will be completed with Deans and Associate Deans to determine the process needed to complete cost allocations timely. Anticipated Completion Date: July 1, 2025

View Audit 352153

Finding 551536 (2024-001)

Significant Deficiency 2024

Bay Area Air Quality Management District

CA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.435 § 200.459

View of Responsible Officials and Corrective Action Plan Air District Management concurs with the recommendation under Finding Reference Number F-2024-001. Upon review of the supporting travel expense documentation, management has found no discrepancies. Moving forward, the Air District will contin...

View of Responsible Officials and Corrective Action Plan Air District Management concurs with the recommendation under Finding Reference Number F-2024-001. Upon review of the supporting travel expense documentation, management has found no discrepancies. Moving forward, the Air District will continue to ensure that all supporting travel documentation agrees with the corresponding invoices to maintain compliance and accuracy. Regarding the overstatement of program expenditures, the Air District will initiate the recovery of the identified overcharges by deducting the amount from future reimbursement requests submitted to the Department of Homeland Security (DHS). Specifically, the Air District plans on recovering the $9,316 in overcharges from the contractor for fiscal year ending June 30, 2024. Additionally, the Air District is in the process of reviewing Fiscal Year 2025 invoices to identify any potential overcharges and will request reimbursement from the contractor, as necessary. To strengthen oversight and compliance, the Air District has begun implementing process changes as of February 2025. These changes ensure that consultant invoices align with the terms of the Air District’s contract prior to approval and payment processing. Name: Daniel Meer Title: Manager, Government Outreach & Special Projects Email: dmeer@baaqmd.gov

View Audit 352146 Questioned Costs: $1

Finding 551510 (2024-002)

Significant Deficiency 2024

Homeless Assistance Leadership Organization, Inc.

WI

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

Action in response to finding: The Organization will either add internal resources to address the matters noted in the finding or outsource its accounting function to a third party with these capabilities. Name of the contact person responsible for corrective action: Yvonne MacDonald Hames Planned c...

Action in response to finding: The Organization will either add internal resources to address the matters noted in the finding or outsource its accounting function to a third party with these capabilities. Name of the contact person responsible for corrective action: Yvonne MacDonald Hames Planned completion date for corrective action plan: June 30, 2025

View Audit 352116

Finding 551506 (2024-003)

Significant Deficiency 2024

Clarkson University

NY

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Management accepts this finding. The error on the verification (1 student) was made by a former staff that did not verify the student wages. Clarkson’s procedure clearly states the income is required to be verified, however the former staff member made an error in processing this verification. Impr...

Management accepts this finding. The error on the verification (1 student) was made by a former staff that did not verify the student wages. Clarkson’s procedure clearly states the income is required to be verified, however the former staff member made an error in processing this verification. Improvements to the training process have been implemented including emphasis on the requirement that staff verify income as part of the review process. A multi-tier review system has been implemented whereby after the initial review process has been completed, verification documents are submitted to the Director who then performs a second review to ensure that the initial review process was correctly followed and that the data is reliable. Anticipated Completion Date December 2024 - completed Responsible Person Nicole Adner, Director of Financial Aid

View Audit 352112

Finding 551505 (2024-002)

Material Weakness 2024

Clarkson University

NY

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Management accepts this finding and notes there were issues with the disbursement records that prevented them from being sent to COD. Unexpected turnover in the workforce resulted in 25% normal processing capacity during the timeframe in question. Staffing levels in that area have been fully restore...

Management accepts this finding and notes there were issues with the disbursement records that prevented them from being sent to COD. Unexpected turnover in the workforce resulted in 25% normal processing capacity during the timeframe in question. Staffing levels in that area have been fully restored with appropriate training to the employees. A formal schedule has been developed whereby records are reconciled and sent to COD on a weekly basis to reduce the risk of late filings. In addition, the University is considering methods of improved redundancy and backup to prevent systemic issues going forward. Anticipated Completion Date December 2024 - completed Responsible Person Nicole Adner, Director of Financial Aid

View Audit 352112

Finding 551444 (2024-006)

Significant Deficiency 2024

Volunteers of America Western Washington and Subsidiary

WA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.430

We acknowledge BDO’s recommendation to ensure consistent approval and retention of timesheets by both employees and supervisors for each pay period requested for reimbursement. However, VOAWW asserts that we have established controls in place to obtain and retain timesheet approvals, and the two ins...

We acknowledge BDO’s recommendation to ensure consistent approval and retention of timesheets by both employees and supervisors for each pay period requested for reimbursement. However, VOAWW asserts that we have established controls in place to obtain and retain timesheet approvals, and the two instances of missing approvals identified in the audit were due to human error rather than a lack of controls. To prevent such occurrences in the future and reinforce our existing procedures, we will continue implementing and strengthening the following controls: • Proactive Timesheet Approval Monitoring – Reports are regularly run to identify missing timesheet approvals before payroll is processed. Employees and supervisors with outstanding approvals receive reminders to ensure further action as needed, including notifying program directors about missing timesheet submissions or approvals resulting in out-of-compliance with federal awards and Uniform Guidance. • Real-Time Payroll Processing Checks – During payroll processing, additional reminders are sent to employees and supervisors who have not yet approved their timesheets, further reducing the likelihood of omissions. • Additional Approval Outside the System – In response to BDO’s recommendation, we will require managers to email Payroll at the end of every pay period affirming that they have reviewed and approved all timecards. This additional layer of approval ensures that even if a manager forgets to approve a timesheet in the system, there is still documented confirmation of their review. • Post-Payroll Compensating Control Implemented in FY24 – To mitigate any risk of over/undercharging grants due to miscoded time from unapproved timesheets, a compensating control was introduced in FY24. This process requires Program Management to review and approve a post-payroll report identifying any discrepancies in time allocations, ensuring that all time charged to grants is accurate and properly approved. • Documentation and Continuous Improvement – VOAWW provided attestations to BDO where available and acknowledges that the compensating control was not fully implemented during FY23 but was in place for most of FY24. Moving forward, we will ensure that this control is consistently applied across all programs. By maintaining and strengthening these controls, including the additional email approval process, we are confident in our ability to ensure proper timesheet approvals while mitigating any risk of inaccurate grant charging. Responsible Individual: Claire Danielson, Controller Estimated time of completion: June 2025

View Audit 352105

Finding 551395 (2024-001)

Significant Deficiency 2024

The Montessori Network

IL

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

Audit Recommendation: Procedures should be consistently applied requiring the reconciliation of submitted personnel activity reports to the employees' actual costs allocated and charged to federal and other programs. Planned Corrective Actions: This finding was initially identified during fiscal ye...

Audit Recommendation: Procedures should be consistently applied requiring the reconciliation of submitted personnel activity reports to the employees' actual costs allocated and charged to federal and other programs. Planned Corrective Actions: This finding was initially identified during fiscal year 2020, and corrective actions were taken by the School in 2021. To address the issue, the School implemented new procedures that require a monthly review by management, which includes a detailed reconciliation of submitted personnel activity reports to vouchers prepared for federal and other programs. This reconciliation process helps to ensure that payroll cost allocation accurately reflects the submitted personnel activity reports. In addition, the School has made changes to its payroll system to ensure accurate time tracking for its various programs. This includes changing the service provider responsible for voucher submissions. These changes will help to prevent similar issues from occurring in the future and ensure that employee-related costs are accurately allocated to the appropriate programs. As of 2022, the School has successfully implemented these changes and continues to review and monitor its procedures to maintain compliance with federal and other program regulations. Finding was repeated during FY23 and FY24, as the School was in the process of transitioning accountants and implementing control procedures during the period of exceptions noted. Anticipated Completion Date: June 30, 2024 Contact Person: Rita Nolan, Executive Director

View Audit 352104

Finding 551220 (2024-020)

None 2024

Upshur County Board of Education

WV

Questioned Costs School Nutrition Programs Matching / Level of Effort / Earmarking § 200.334 § 200.403

The Board has developed procedures to ensure that all purchase orders are approved before orders are placed, all expenditures are properly authorized by the respective program director and supporting documentation is adequately maintained. The Board is using a requisition form in Droplet to achieve ...

The Board has developed procedures to ensure that all purchase orders are approved before orders are placed, all expenditures are properly authorized by the respective program director and supporting documentation is adequately maintained. The Board is using a requisition form in Droplet to achieve this goal. All employees authorized to make or approve purchases have been trained on purchasing procedures outlined in the Purchasing Policies and Procedures Manual for Local Educational Agencies in the State of West Virginia by the WVDE Office of School Finance on 2/23/2024.

View Audit 352084 Questioned Costs: $1

Finding 551208 (2024-019)

Material Weakness 2024

Upshur County Board of Education

WV

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.334

The Board will establish procedures that will ensure compliance with guidance set forth in Title 2 U.S. Code of Federal Regulations (CFR) Part 200 for Special Education.

View Audit 352084 Questioned Costs: $1

Finding 551196 (2024-017)

None 2024

Upshur County Board of Education

WV

Questioned Costs School Nutrition Programs Allowable Costs / Cost Principles

The Board will develop a Food Service Collection Policy and attempt to collect the outstanding balances on the receivables related to the National School Lunch Program.

View Audit 352084 Questioned Costs: $1

Finding 551177 (2024-007)

Significant Deficiency 2024

The City of New York

NY

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

Finding No. 2024-007 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): HRA implemented the corrective actions noted in our response to the Fiscal 2023 Single Audit findings. In Nove...

Finding No. 2024-007 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): HRA implemented the corrective actions noted in our response to the Fiscal 2023 Single Audit findings. In November of 2023, HRA hired an Executive Director for the Home TBRA program, updated the quality assurance evaluation tool and trained staff on the differences of budgeting the “gross” and “net” income. Note that HRA began closing out the TBRA tenants with renewal lease dates starting on 8/1/2023, as the program fully closed and transitioned to the City Fighting Homelessness and Eviction Prevention Supplement (“CityFHEPS”) by the 6/30/24 HRA- Housing Preservation and Development Memorandum of Understanding expiration date. Although the rental assistance portion of the HOME TBRA program began phasing out, the following corrective actions were implemented as part of the Fiscal 2023 Single Audit recommendation: • Supervisory staff were retrained on case review and instructed to do a thorough and comprehensive review of the budget and documentation received to inform case decisions. There have been on-going team and individual meetings, informational sessions and trainings with staff involved with TBRA to improve performance and outcome. Anticipated Completion Date: Not Applicable. As noted above, the Rental Assistance portion of the program has been taken over by CityFHEPS. Person(s) Responsible for Implementation: Jordan Worrell, HTBRA Executive Director worrellj@hra.nyc.gov (929)-252- 5403

View Audit 352075

Finding 551139 (2024-003)

Significant Deficiency 2024

Unique People Services - Aids Programs, Inc..

NY

Questioned Costs Allowable Costs / Cost Principles § 200.430

UPS-AIDS has always used the budget allocations for wages and salaries in the past until this year that it becomes an issue. The finding was not corrected because management did not have sufficient time to prepare for the subsequent year after the previous year was submitted in a very short period o...

UPS-AIDS has always used the budget allocations for wages and salaries in the past until this year that it becomes an issue. The finding was not corrected because management did not have sufficient time to prepare for the subsequent year after the previous year was submitted in a very short period of time. Nevertheless, we have agreed to comply as they have requested. However, we have agreed to comply with 2 CFR 200.430. Ive Pierre, Chief Financial Officer, will implement a time study by June 30, 2025.

View Audit 352063 Questioned Costs: $1

Finding 551134 (2024-001)

Significant Deficiency 2024

Young at Heart Resources

MO

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

Agency Response: Currently, Young at Heart follows policies and procedures for holidays, week hours, etc. CEO and CFO are aware we must follow our policies. We have changed the work week policy and the holiday listings in our policies. Creating new policies was part of the corrective action plan wit...

Agency Response: Currently, Young at Heart follows policies and procedures for holidays, week hours, etc. CEO and CFO are aware we must follow our policies. We have changed the work week policy and the holiday listings in our policies. Creating new policies was part of the corrective action plan with the DHSS. The policies were created and approved by Young at Heart Board in July 2024. Employees work a 36 hour week and receive 13 paid holidays. The credit card procedure now is being followed as it should. This was also on the Correctve Action Plan with DHSS. Both the previous CEO (Michael Stopka) and CFO (Shari Harris) are no longer employed with the agency. When I started as CFO, the current interim CEO Freda Miller and I called the board chair regarding the personal charges by Michael Stopka on the corporate credit card. The board chair was unaware of this and would address the issue and make sure he not only didn’t use the card for personal charges but would not pay it online and bypass the internal control function of accounts payable and cash disbursements. The current procedure of all purchases must be approved by the CEO and CFO prior to purchase. Once the item is purchased, the receipt and the requisition is sent to the fiscal assistant who matches the receipts to the credit card bill. Once all items are accounted for, the fiscal assistant will cut a check. The check will then be signed by CEO and a board member. The credit card bill is no longer being paid on-line. I believe the internal control problems have been addressed both on the corrective action plan with MO DHSS and by current management. These items were corrected in July 2024 after M. Stopka & S. Harris had left the agency.

View Audit 352061

Finding 551133 (2024-009)

Material Weakness 2024

County of Solano

CA

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Foster Care Federal Assistance Listing Number: 93.658 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Allowable Activities and Allowed Costs Type ...

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Foster Care Federal Assistance Listing Number: 93.658 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Allowable Activities and Allowed Costs Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County has policies and procedures as well as systematic processes and oversight set up to ensure accurate assessments and determinations are made regarding the Federal or Non-Federal Eligibility of youth in the Foster Care system. It is Solano County’s policy to conduct these assessments at the onset of the case and ensure quality documentation. In addition, the Foster Care unit has a Lead worker and Supervisor who conduct periodic reviews of open cases to ensure accuracy of documentation and adherence to timelines are met. The specific corrective actions identified in this audit found errors related to the migration of data to the CalSAWS program in 2023, where an identified payment was incorrectly identified (Non-Federal to Federal) due to errors or information which existed in CalWin and were transferred improperly to CalSAWS. These conversion errors occurred automatically. As a result, the Foster Care Eligibility Unit has implemented the following changes. • Correction to identified payment: o The identified case was corrected immediately, and all payments adjusted as appropriate. • Changes to workflow to ensure accuracy: o The entire caseload of open Foster Care Eligibility cases will be reviewed to ensure that the original determination or as found in the FC3 or FC3A and granting comments, is correctly input in CalSAWS, and any payment errors corrected as needed. o The case aid code (noting eligibility type) will be included next to the youth’s name to ensure that it shows in the workload report in CalSAWS to ensure the information is easily accessible and any future errors can be identified. o Cases will be reviewed to ensure the above changes are completed through the unit supervisor’s ongoing qualitative review of cases. • The Foster Care Eligibility Supervisor will discuss the findings and requirement with subordinate staff in the following ways: o Unit meeting communication regarding Corrective Action findings and Agency steps to remediate. o Issue a reminder to all staff regarding the above remediation plan. Responsible Individual(s): Kim McDowell, Social Services Manager Neely McElroy, Deputy Director, Child Welfare Services Anticipated Completion Date: May 31, 2025

View Audit 352056 Questioned Costs: $1

Finding 551081 (2024-002)

Significant Deficiency 2024

Housing Authority of the Township of North Bergen

NJ

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs § 200.423 § 200.438 § 200.459 § 200.475

View of Responsible Officials and Corrective Actions: The Authority has recognized the deficiencies related to payroll and will implement internal control procedures that will ensure compliance with the Authority's internal control policies and personnel policy. Julio Marenco, Interim Executive Dire...

View of Responsible Officials and Corrective Actions: The Authority has recognized the deficiencies related to payroll and will implement internal control procedures that will ensure compliance with the Authority's internal control policies and personnel policy. Julio Marenco, Interim Executive Director, will be responsible to implement this corrective action by June 30, 2025.

View Audit 352015 Questioned Costs: $1

Finding 551074 (2024-003)

None 2024

Mountain Area Regional Transit Authority

CA

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

Identifying Number: SA 2024-003 Description of Finding: During the audit of payroll expense testing, it was noted that five samples have Personnel Action Forms (PAF) without the signature of the General Manager. In addition, one of those five samples has a variance between the pay rate per PAF and p...

Identifying Number: SA 2024-003 Description of Finding: During the audit of payroll expense testing, it was noted that five samples have Personnel Action Forms (PAF) without the signature of the General Manager. In addition, one of those five samples has a variance between the pay rate per PAF and pay rate per payroll register. Per current policies and procedures, for pay rate changes, a PAF should be created by the HR Manager and signed by the General Manager. Additionally, MARTA was unable to provide PAF for four samples. Corrective Actions Taken or Planned: 1. We will review our procedures on processing PAF, communicate more effectively to close loop on paperwork process, and confirm authorized signatures. 2. We will review all files for completed PAF forms and practice better diligence going forward in maintaining all documentation in personnel files. Personnel responsible for implementation: Jacob Phillips, HR Manager Anticipated completion date: Effective immediately

View Audit 352013

Finding 549905 (2024-018)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.302 § 200.430

2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance r...

2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance review of compensation costs charged to federal sponsors. Huron Consulting routinely works with Carnegie R1 institutions to review research compliance issues. Huron conducted a detailed review of an extensive data set for ESC payments made to USU employees, focusing on employees who had salary charged to federal grants or designated as a grant cost share. This review identified limited instances (1) when salaries directly charged to sponsored projects included extra service compensation in the institutional base salary and (2) when extra service compensation was charged to federal sponsors. Overall, the review found that the vast majority of USU ESC payments (referred to as secondary payments in the internal audit) were not charged to federal sponsored awards. Out of a total population of $5.8 million ESC payments reviewed, the unallowed compensation costs related to ESC is approximately $140,000. USU is in the process of addressing the unallowable compensation costs by removing unallowable charges on open awards and refunding unallowable charges on closed awards. 2) Policies and required documentation for ESC. ESC Policies: USU is reviewing its policies associated with ESC and institutional base salary (IBS) (both currently defined in USU Policy 376: Extra Service Compensation). A working group has been established that includes the Provost’s Office, the President’s Office, the Office of Research and Human Resources to develop updated procedures for requesting ESC. Once in place, a new Extra Service Compensation website will be rolled out that will provide guidance on the policy, acceptable uses of extra-service Compensation, and training materials. In conjunction with the website development, a communication plan to inform stakeholders, especially approving department heads and administrators, will be developed. Institutional Base Salary Policy and Procedures: USU will create and implement an Institutional Base Salary policy that aligns with federal requirements and industry best practices and specifically defines salary components and the associated pay codes that are included and excluded from an employee’s institutional base salary. USU will also update its time and effort certification system with correct institutional base salary mapping. 3) Internal controls for sponsored program compensation USU will implement the following improvements in its internal controls: Revised ESC Form. USU has revised its ESC Form to include documentation / calculation demonstrating payment is commensurate with institutional base salary. Revised ESC Application and Approval Process: USU has already updated the internal ESC review process to include appropriate controls to ensure that all ESC requests are reviewed for Uniform Guidance and USU policy requirements. In this regard, all ESC requests at USU are now reviewed by the Office of Sponsored Programs in the context of all funding sources associated with the applicant (including cost share indexes). This change directly addresses prior routing based on the source of funding which resulted in the Office of Research/Sponsored Programs being bypassed for state-funded ESC requests. Certification language has been inserted at appropriate approval levels to ensure that employees are not receiving ESC related to their primary position/workload. Improved Definitions of Primary Work Statement: USU has initiated a collaborative effort between Human Resources, the Provost’s Office, and the Office of Research to clearly define the primary work assignment for faculty via the role statement or annual work plans to clarify the full workload associated with the IBS. Increased Compliance Monitoring: After-the-fact monthly review of ESC payments is being collaboratively performed between the Office of Research and Provost’s Office. Additionally, USU has reorganized its operations to house post-award research administrators within the Office of Research and added an additional supervisory position to manage post award compliance and management. USU will charge central-post award research administrators with monitoring salary charges to sponsored awards and cost share accounts as a secondary internal control. Research Incentive Programs: The Office of Research will establish permissible conditions and components for research incentive programs and any and all proposed programs will be reviewed and approved by the Office of Research before implementation. 4) Adequate training to university personnel regarding sponsored programs compensation compliance. Uniform Guidance training for faculty and staff: USU is building and incorporating new training modules for those managing federal awards which will include guidance on allowable compensation costs and determining institutional base salary. ESC Training: USU has developed a new required annual training for anyone requesting or approving ESC from all types of funding sources at USU (delivered via USU’s Learn Blue system). This training addresses requirements for ESC and employees’ role and responsibilities for compliance requirements. Additional training regarding time and effort certification will be developed. Pay Code Training: USU will provide additional training and education for departmental and payroll staff responsible for coding and processing salary across the institution. Responsible Person: Lisa M. Berreau Vice President for Research Utah State University 435-797-3509 Anticipated completion date of corrective action plan: Actively in progress and full completion by Jan. 1, 2026.

View Audit 352012

Finding 548761 (2024-008)

Significant Deficiency 2024

State of Utah

UT

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

2024-008. Non-Payroll Expenditures Did Not Receive Adequate Reviews State Agency: University of Utah Research & Development Federal Agency: Department of Health and Human Services The Controller’s Office will work directly with the identified PI’s to provide additional training and understanding of ...

2024-008. Non-Payroll Expenditures Did Not Receive Adequate Reviews State Agency: University of Utah Research & Development Federal Agency: Department of Health and Human Services The Controller’s Office will work directly with the identified PI’s to provide additional training and understanding of the importance of appropriate and timely approvals. In addition, the Controller will work with the Office of Sponsored Projects and the Financial Reporting & Accounting office to review current training processes, as well as the process for notification and follow up with those AE’s/PI’s who do not meet the standard set forth in policy. Contact Person: Steven Phillips Anticipated Correction Date: 6/30/2025

View Audit 352012

Finding 548699 (2024-016)

None 2024

State of Utah

UT

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

2024-016. Working Capital Reserves in Excess of Federal Guidelines State Agency: Department of Governmental Operations Federal Agency: Various Division of Purchasing and General Services Cooperative Contract Management Fund – State Purchasing continues to decrease the administrative fees on state co...

2024-016. Working Capital Reserves in Excess of Federal Guidelines State Agency: Department of Governmental Operations Federal Agency: Various Division of Purchasing and General Services Cooperative Contract Management Fund – State Purchasing continues to decrease the administrative fees on state cooperative contracts as each contract expires and is rebid. This is a slow process since State Purchasing has nearly 1,300 cooperative contracts with an average 5-year term. With only about 20% of the contracts expiring each year, this is an ongoing and slow process. Although State Purchasing is allowed under law to collect up to a 1.0% administrative fee on each cooperative contract, currently the average administrative fee is 0.35%. The excess reserves are also being reallocated to other programs. These allocations are intended to both reduce the excess reserve balance and to create efficiencies within the division to better serve state agencies. Federal Surplus Property Fund – The excess reserves are to be used in relocating Surplus to the Taylorsville State Office Building in March 2025. Contact Person: Windy Aphayrath (waphayrath@utah.gov, 801-957-7138), Director, Division of Purchasing and General Services Anticipated Correction Date: June 30, 2025 Division of Finance Purchasing Cards Fund (P-Card) – The system implementation was completed at the end of calendar year 2024. State Finance is working to analyze the annual costs of the system, develop a cost allocation strategy between the travel and P-Card programs, and adjust travel rates to cover the travel program's ongoing costs. The P-Card program will then distribute any remaining P-Card rebates to state agencies respective to their spending, if applicable. This effort will eliminate any excess federal reserves in the P-Card fund by the end of fiscal year 2025. Contact Person: Allyson Branch (abranch@utah.gov, 801-597-3523), Assistant Director, Division of Finance Anticipated Correction Date: June 30, 2025 Division of Risk Management Workers’ Compensation Fund – The Division of Risk Management has received approval from the Utah Legislature to reduce rates for workers’ compensation in fiscal year 2026. This will take effect on July 1, 2025. The division will also request at the next Legislative session to reallocate excess reserves from the Workers’ Compensation Fund to the Property Fund. This will be completed by July 1, 2026. Contact Person: Rachel Terry (rachelgterry@utah.gov, 801-702-7445), Director, Division of Risk Management, Anticipated Correction Date: July 1, 2026 Division of Technology Services Communication Services – The Division has worked to reduce the excess reserves and has been successful in decreasing the balance compared to the previous year. In addition, the current year rate was calculated to continue decreasing the excess reserve balance. Next year rates have also been adjusted to further reduce the excess reserve balance. We are working to balance reductions in retained earnings while maintaining services until the products reach the end of their lifecycle. Network Services – The Division is estimating that excess reserves will decrease as a result of anticipated increases in expenses over fiscal years 2025, 2026, and 2027 to support the migration to a cloud-based platform. We will continue to monitor rates and expenses as the technology environment continually changes. Printing Services – The Division has set the current year rate to recover costs in order to reduce the excess reserves. The threshold for this program has a small limit for a product with a very high volume. Print demand this year has been low, and we are forecasting this to be fully corrected by the end of fiscal year 2025. Contact Person: Jake Hennessy (jakehennessy@utah.gov, 385-271-2301), Executive Finance Director, Department of Government Operations Anticipated Correction Date: June 30, 2025 Division of Human Resource Management Human Resources Field Services – A cost allocation plan was developed to better align expenses with the specific service area supported. Field Service rates were lowered for fiscal year 2025. We anticipate continuing to fine tune rates to bring the Field Service reserve balance down. Contact Person: John Barrand (jbarrand@utah.gov, 801-957-9350), Director, Division of Human Resource Management Anticipated Correction Date: June 30, 2025

View Audit 352012

Finding 548694 (2024-009)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took ap...

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took approval actions on these cases will be scheduled to discuss what led to the incorrect decision and review the policy and procedure for learning. In addition, all eligibility workers who manage refugee programs will receive training on common error elements. All one-on-one meetings and team training will be completed by April 30, 2025. Anticipated correction date: April 30, 2025 Responsible person: Muris Prses, Division Director, Eligibility Services Division, 801-889-9712

View Audit 352012 Questioned Costs: $1

Finding 548693 (2024-007)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applic...

2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applicable period of performance in which the work was performed, and expenses were incurred and will ensure that costs are subsequently charged to the corresponding grant award. Anticipated correction date: January 31, 2025 Responsible person: Nathan Harrison, Executive Finance Director, 801-808-0676

View Audit 352012 Questioned Costs: $1

Finding 548660 (2024-002)

Significant Deficiency 2024

Food Lifeline

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency § 200.303

Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and t...

Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and the total revenues earned under each award to ensure the amounts are consistent with those reported in the schedule of expenditures of federal awards. Anticipated Completion Date: June 30, 2025

View Audit 351990

Corrective Action Plans

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