Corrective Action Plans

Finding 544116 (2024-004)

Material Weakness 2024

New Reach, Inc.

CT

Allowable Costs / Cost Principles

Finding No. 2024-004: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Description of Finding: The Organization was unable to produce records supporting the work performed or support the distribution of wages. Statement of Concurrence or Nonconcurrence: The organization agrees wit...

Finding No. 2024-004: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Description of Finding: The Organization was unable to produce records supporting the work performed or support the distribution of wages. Statement of Concurrence or Nonconcurrence: The organization agrees with this finding. Corrective Action: With the implementation of a revised cost allocation plan noted above the Organization now require all employees to attest the accurate allocation of their time via personnel activity reports (PARS) Allocation of payroll costs will be supported by the PARS and the calculation will be attached to each allocation journal entry within the general ledger. Name of Contact Person: Kellyann Day Chief Executive Officer, (203) 492-4866, kday@newreach.org Projected Completion Date: The project is anticipated to be completed during fiscal year 2025.

View Audit 350907

Finding 544100 (2024-003)

Material Weakness 2024

New Reach, Inc.

CT

Allowable Costs / Cost Principles

Finding No. 2024-003: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Description of Finding: The Organization was unable to produce documentation supporting its cost allocation plan ("CAP"). Operating expenditures reported on submitted grant reports did not consistently reconcil...

Finding No. 2024-003: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Description of Finding: The Organization was unable to produce documentation supporting its cost allocation plan ("CAP"). Operating expenditures reported on submitted grant reports did not consistently reconcile directly back to the underlying accounting records. Statement of Concurrence or Nonconcurrence: The organization agrees with this finding. Corrective Action: Subsequent to year end the organization updated its CAP Beginning in July the allocation calculation and documentation will be attached to all allocation journal entries. Name of Contact Person: Kellyann Day Chief Executive Officer, (203) 492-4866, kday@newreach.org Projected Completion Date: The project is anticipated to be completed during fiscal year 2025.

View Audit 350907

Finding 544083 (2024-001)

Significant Deficiency 2024

Wide Ruins Community School

AZ

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Significant Deficiency

Finding Number: 2024‐001 Program Names/Assistance Listing Titles: Indian School Equalization, Indian Education Facilities, Operations and Maintenance Assistance Listing Numbers: 15.042, 15.047 Contact Person: Aurelia Tapaha, Business Manager; Stephanie Woody, Business Technician; Donna Manuelito, Pr...

Finding Number: 2024‐001 Program Names/Assistance Listing Titles: Indian School Equalization, Indian Education Facilities, Operations and Maintenance Assistance Listing Numbers: 15.042, 15.047 Contact Person: Aurelia Tapaha, Business Manager; Stephanie Woody, Business Technician; Donna Manuelito, Principal Anticipated Completion Date: July 2025 Planned Corrective Action: The School will review the procurement flowcharts and required documents for Business Technician. The School will obtain training for chart of accounts training for business staff along with procurement training. Business staff and administrators will keep abreast of law changes, GASB updates, and budget changes with grants received. The School will review school credit and implement a timeframe where the no use of the credit card is enforced. The School will collect all required documents to process payments. The entire balance will be paid in full amount for each month. Training on use of credit cards will be given during orientation. Update of Financial Policies to reflect changes to OMB Circular. Repeat finding due to change in Administration and our focus to meet requirements of BIE and Department of Dine Education took precedence.

View Audit 350888

Finding 544078 (2024-001)

Material Weakness 2024

Gaudenzia Inc.

PA

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

2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: HOME Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Agencies: City of Philadelphia, Redevelopment Authority: Venango – Loan Thompson Street – Loan County of S...

2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: HOME Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Agencies: City of Philadelphia, Redevelopment Authority: Venango – Loan Thompson Street – Loan County of Schuylkill - Home Investment Partnerships and Housing Trust Funds Programs: Fountain Springs - Loan Mayor and City of Baltimore: Baltimore Housing - Park Heights Women and Children - Loan Condition: As part of the eligibility requirement for the HOME Investment Partnership program, we are required to review files of client residents who were provided residential drug and alcohol treatment services at the Organization’s locations in Venango (Re-Entry), Fountain Springs, Thompson Street, and Park Heights Women and Children. We sampled a total of 40 resident clients at these four locations covered by HOME loans and requested documentation within client resident files, including proof of residency, proof of income (low income or homeless), and lease or housing agreement (depending on program requirements). Of the 40 resident client files reviewed, management was unable to provide any proof of income or determination of homelessness or residency for 24 files. Recommendation: We recommend that management adopt policies and procedures including both the communication of compliance requirements between staff and locations and the development of documentation and processes to assist in how income eligibility is determined. This includes management developing certain income verification documents that can be used as part of the intake process for determining the eligibility of the residential client. In addition, process will need to be developed for the redetermination of income if a residential client has lived over a year at a particular location. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Gaudenzia, Inc believes that had the requisite documentation been completed, it would have been in compliance with the low-income compliance requirement as the referral sources that were used to place the clients in the program are all coming from CBH as well as other MCO funded partners. These referral sources are typically Medicaid clients and are typically well below the low-income requirement thresholds. Action taken in response to finding: Gaudenzia, Inc has incorporated existing low-income eligibility procedures to the Project Home Loans program sites to be in full compliance of the eligibility requirements. These procedures will be reinforced within our programs to ensure the requisite documentation is in place. Name of the contact person responsible for corrective action: Nikant Ohri, Chief Financial Officer, nikant.ohri@guadenzia.org (610) 860-2061 Planned completion date for corrective action plan: June 30, 2025

View Audit 350881

Finding 544068 (2024-005)

Significant Deficiency 2024

Mandaree Public School District No 36

ND

Allowable Costs / Cost Principles

Contact Person: Business Manager and Human Resource Manager Planned Corrective Action: The District currently does have processes and controls in place to ensure grant expenditures have been approved. Specific to this audit finding of missing salary authorization forms, the Business Manager will...

Contact Person: Business Manager and Human Resource Manager Planned Corrective Action: The District currently does have processes and controls in place to ensure grant expenditures have been approved. Specific to this audit finding of missing salary authorization forms, the Business Manager will meet with the Human Resource Manager to review the current control and approval processes for employee salaries and make changes as appropriate. Planned Completion Date: January 2025

View Audit 350871

Finding 544065 (2024-004)

Significant Deficiency 2024

Mandaree Public School District No 36

ND

Allowable Costs / Cost Principles

Contact Person: Business Manager and Human Resource Manager Planned Corrective Action: The District currently does have processes and controls in place to ensure grant expenditures have been approved. Specific to this audit finding of missing salary authorization forms, the Business Manager will...

Contact Person: Business Manager and Human Resource Manager Planned Corrective Action: The District currently does have processes and controls in place to ensure grant expenditures have been approved. Specific to this audit finding of missing salary authorization forms, the Business Manager will meet with the Human Resource Manager to review the current control and approval processes for employee salaries and make changes as appropriate. Planned Completion Date: January 2025 and ongoing

View Audit 350871

Finding 544057 (2024-002)

Significant Deficiency 2024

Intecare, INC

IN

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

2024-002 Supportive Services for Veteran Families – Assistance Listing No. 63.033 Recommendation: CLA recommends the control process be reviewed and enhanced to ensure consistency in obtaining proper approvals. Explanation of disagreement with audit finding: There is no disagreement with the audit...

2024-002 Supportive Services for Veteran Families – Assistance Listing No. 63.033 Recommendation: CLA recommends the control process be reviewed and enhanced to ensure consistency in obtaining proper approvals. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Adjusted who was responsible for payroll approvals. Name(s) of the contact person(s) responsible for corrective action: Lara Williams Planned completion date for corrective action plan: 11/1/2024

View Audit 350867

Finding 542032 (2024-002)

Significant Deficiency 2024

The Pennsylvania State University

PA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Finding Number: 2024-002, Effort Certification Condition: One of the internal controls that the University has designed related to ensuring that personnel expenses charged to federal grants were accurate is an effort certification that is completed at least annually. This control was not operating ...

Finding Number: 2024-002, Effort Certification Condition: One of the internal controls that the University has designed related to ensuring that personnel expenses charged to federal grants were accurate is an effort certification that is completed at least annually. This control was not operating effectively during the year ended June 30, 2024, as certain effort certifications were not completed timely. Planned Corrective Action: Penn State raised awareness of the late effort certification issue at various committee and council meetings during Fall 2024 and enforced compliance with our existing policy. These meetings involve research leadership at all colleges, such as Associate Deans for Research, College Research Administration Officers, and College Financial Officers. Penn State followed its policy on overdue effort certifications, and we have implemented additional internal controls in the process. The University’s Office of the Senior Vice President for Research has restructured oversight of effort certification, along with many other post award financial matters, to a newly created office, Post Award Contractual Compliance (PACC). This office includes the existing Research Accounting Office (which was part of the Office of Budget and Finance prior to July 1, 2024), and Penn State has hired an Assistant Vice President to oversee this team. A new suboffice, led by a new director, within PACC is the Financial Analysis and Compliance Office (FACO), which is responsible for central oversight and training over the effort certification process. This office has recently created a new dashboard to monitor the completion of effort certifications and works closely with business units within Penn State to ensure timely completion via sending out reminders, holding meetings, and providing training on the process. Contact person responsible for corrective action: John Hanold, Associate Vice President for Research; Director, Office of Research Administrative Services Anticipated Completion Date: June 30, 2025

View Audit 350858

Finding 542015 (2024-001)

Material Weakness 2024

Urban League of Portland

OR

Questioned Costs Allowable Costs / Cost Principles Period of Performance

Contact Person NAME: Julia Delgado PHONE: (503) 280-2600 E-Mail: jdelgado@ulpdx.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned The Urban League of Portland is committe...

Contact Person NAME: Julia Delgado PHONE: (503) 280-2600 E-Mail: jdelgado@ulpdx.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned The Urban League of Portland is committed to an environment of continuous improvement. Further training shall be provided to Program Managers regarding the organizations’ documented internal controls and the importance of adhering to the established approval process. Urban League has currently hired a seasoned Controller and is in the process of hiring an experienced Accounting Manager. Tracking expiring grants more thoroughly and having further reviews in place to assure transactions are recorded within the grant’s agreed upon period of performance shall provide confidence expenses are recorded properly. Anticipated Completion Date: 05/01/2024

View Audit 350845 Questioned Costs: $1

Finding 542010 (2024-005)

Significant Deficiency 2024

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.306 § 200.403

Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of match expenditures, testing noted 5.15 hours identified as Medicaid hours for one employee were not removed from...

Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of match expenditures, testing noted 5.15 hours identified as Medicaid hours for one employee were not removed from the employee’s total hours when calculating the amount of match for the federal program. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could claim as match disallowed costs under the federal award and would not be able to detect and correct noncompliance in a timely manner. The employee’s Medicaid hours were not properly included within a revenues report due to the employee’s provider number not being included within the report parameters. Responsible Individuals: CEO (Dan Ries) Corrective Action Plan: CEO will double check and confirm that all revenue reports run have data for the correct staff to ensure that the accurate information is being used to calculate match hours. Anticipated Completion Date: September 2024.

View Audit 350836 Questioned Costs: $1

Finding 542009 (2024-004)

Significant Deficiency 2024

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

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

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.696 Program Name: Certified Community Behavior Health Clinic Expansion Grants Finding Summary: During testing of expenditures, the following was identified: a) ClickTime timecard, which trac...

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.696 Program Name: Certified Community Behavior Health Clinic Expansion Grants Finding Summary: During testing of expenditures, the following was identified: a) ClickTime timecard, which tracks federal and nonfederal hours for employees, did not properly reflect the employees total federal and nonfederal hours being paid within the payroll register (1 instance). b) Calculation errors for expenses allocated to the grant (3 instances). c) Employee tracked 2.7 hours under the federal program and a nonfederal program line in ClickTime (1 instance) causing it to be double counted. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. An employee entered 8 hours of PTO into ClickTime for two days each; however, the employee was only paid for 4 hours of PTO for each day. The calculation errors were due to the use of a wrong employee’s allocation percentage and a keying error for payroll expenses for an employee. The secondary review of the employee ClickTime timecards did not identify the incorrectly tracked hours and double tracked time. Also, the secondary review of federal grant expenditure tracking spreadsheet did not identify the calculation errors. Responsible Individuals: Project Directors (Rebecca McCrackin, Missy Martini), Project Accounts Manager (Marsha Bomgaars) and CEO (Dan Ries) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare and reconcile all ClickTime reports with payroll reports using an Excel spreadsheet to identify discrepancies and to ensure the ClickTime timecards and the payroll registers match and all hours are accurately reported. Anticipated Completion Date: September 2024.

View Audit 350836 Questioned Costs: $1

Finding 542008 (2024-003)

Significant Deficiency 2024

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Questioned Costs Allowable Costs / Cost Principles § 200.303

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL#93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of expenditures, the auditor’s noted calculation errors when allocating payroll expens...

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL#93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of expenditures, the auditor’s noted calculation errors when allocating payroll expenses to the federal grant. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. The calculation errors were due to the use of a wrong employee’s allocation percentage, a keying error for the amount of payroll taxes for an employee, and not properly updating the calculation of worker’s compensation based upon the new percentage effective January 1, 2024 for the state of Iowa. In addition, the secondary review of federal grant expenditure tracking spreadsheet did not identify the calculation errors. Responsible Individuals: Staff Supervisors (Sarah Heinrichs) and Project Accounts Manager (Marsha Bomgaars) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare and reconcile all ClickTime reports with payroll reports using an Excel spreadsheet to identify discrepancies and to ensure the ClickTime timecards and the payroll registers match and all hours are accurately reported. Anticipated Completion Date: September 2024.

View Audit 350836 Questioned Costs: $1

Finding 542004 (2024-002)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles Cash Management Reporting

2024-002 C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommen...

2024-002 C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should reassess the design of its controls to ensure submissions to BHSB are made timely within the required 15-day period and that documentation is retained that evidences the review and approval of expenditures submitted to BHSB for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendations. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on capabilities within the system that can be utilized in the execution of review and approval of grant expenditures prior to timely submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as to retain their review and approval evidence. Additionally, management will develop a federal grant policy that includes the requirements for compliance and internal controls for federal grants. The policy will acknowledge that for controls to be designed and operate effectively, there must always be a segregation of duties between the preparer of the control vs. reviewer and that clear documentation must be retained to evidence the execution of the controls. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 350833

Finding 542003 (2024-001)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2024 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) considers the implementation and monitoring of effective internal controls to be one of its most i...

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2024 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) considers the implementation and monitoring of effective internal controls to be one of its most important responsibilities. The Corporation respectfully submits the following corrective action plan regarding the Schedule of Findings and Questioned Costs for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 FINDINGS—FEDERAL AWARD PROGRAMS AUDITS 2024-001 A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles Review and Approval of Purchase Orders Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should obtain documentation that evidences the review and approval of expenditures submitted to Behavioral Health System Baltimore (BHSB). Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendations. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on system capabilities that can be utilized in the execution of review and approval of grant expenditures prior to submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as retain their review and approval evidence. For the specific vendor noted in Finding 2024-001, a grant input field has been added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants. Additionally, management is working with the vendor to ensure the requisition and approval configuration is properly maintained to prevent an approver in the from approving their own requisitions. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 350833

Finding 542001 (2024-002)

Significant Deficiency 2024

Nami Chicago

IL

Allowable Costs / Cost Principles § 200.303

Fiscal Policies and Procedure Alignment with Uniform Guidance Management at NAMI Chicago agrees with this finding and has already taken steps to address this recommendation through the following: • The implementation of expense management platform, Ramp to track and electronically maintain a system...

Fiscal Policies and Procedure Alignment with Uniform Guidance Management at NAMI Chicago agrees with this finding and has already taken steps to address this recommendation through the following: • The implementation of expense management platform, Ramp to track and electronically maintain a system of authorization and approval for all expenses. This system was piloted from September 1, 2024 – December 31, 2024 and implemented as of January 1, 2025. • The hiring of new fiscal staff with expertise in nonprofit financial management and standards, completed by June 30, 2024. • Updates to our fiscal policies and procedures to ensure alignment with Uniform Guidance requirements completed on December 1, 2024.

View Audit 350830

Finding 541996 (2024-004)

Material Weakness 2024

University City District

PA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.327 § 200.328

Finding No. 2024-004: Segregation of Duties and Oversight – Material Weakness in Internal Control over Financial Reporting Contact for Corrective Action: Matt Bergheiser, President The finance department will institute a monthly financial reporting package to be sent to the President of the organi...

Finding No. 2024-004: Segregation of Duties and Oversight – Material Weakness in Internal Control over Financial Reporting Contact for Corrective Action: Matt Bergheiser, President The finance department will institute a monthly financial reporting package to be sent to the President of the organization which will include the monthly financial statements, general ledger detail, a listing of all journal entries made, significant accounts reconciliations, aged payables and receivables, and any significant adjustments in the previous period. Report will also include an update to the Schedule of Federal Awards and other significant grant reporting done in conjunction with the development team. President will review and approve the packet monthly. Expected Completion Date: 3/31/2025

View Audit 350805

Finding 541993 (2024-002)

Significant Deficiency 2024

Bridgehampton Union Free School District

NY

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

2024-002. Allowable Costs/Cost Principles: Final Expenditure Report for a Federal or State Project (FS-10-F) United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Testing of the expenditur...

2024-002. Allowable Costs/Cost Principles: Final Expenditure Report for a Federal or State Project (FS-10-F) United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Testing of the expenditures charged to the grant, determined that costs were in excess of the adjusted budget amount because the actual number of students served was less than the target number of students to be served. Planned Corrective Action: The District should monitor performance indicators for the grant and review final expenditures charged to grants prior to submitting final cost reports to the New York State Education Department for reimbursement. Responsible Contact Person: Peter Daly Interim School Business Administrator Bridgehampton Union Free School District 2685 Montauk Highway Bridgehampton, New York 11932 Anticipated Completion Date: June 30, 2025.

View Audit 350800

Finding 541991 (2024-001)

Significant Deficiency 2024

Bridgehampton Union Free School District

NY

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

2024-001. Allowable Costs/Cost Principles: Compensation – Personal Services United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires...

2024-001. Allowable Costs/Cost Principles: Compensation – Personal Services United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for salaries and wages must be based on records that accurately reflect the work performed.” The documentation should support the distribution of the employee's compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PARs) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District had not prepared periodic certification equivalents for all employees. Planned Corrective Action: The District will monitor procedures to ensure that documentation to support salaries and wages charged to federal awards is in a format that complies with the requirements of the Uniform Guidance Subpart E, 2 CFR §200.430. Responsible Contact Person: Peter Daly Interim School Business Administrator Bridgehampton Union Free School District 2685 Montauk Highway Bridgehampton, New York 11932 Anticipated Completion Date: June 30, 2025.

View Audit 350800

Finding 541975 (2024-002)

Significant Deficiency 2024

Honey Lake Valley Resource Conservation District

CA

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

Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: At the March 27th, 2025 Board Meeting, the District addressed the issue of missing signatures on checks. As a result, the following actions were agreed upon: • The District Manager will ...

Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: At the March 27th, 2025 Board Meeting, the District addressed the issue of missing signatures on checks. As a result, the following actions were agreed upon: • The District Manager will comply with District Policy 3140 at all times. • When possible, Board Members will sign checks at regularly scheduled Board meetings. • If waiting for the next meeting is not feasible, the District will implement the following internal control process, documented in an internal Standard Operating Procedure (SOP): 1. The District Manager will initiate payment and draft the check. 2. The Bookkeeper will log the relevant information into the internal Check Control Log. 3. The District Manager will contact the Board to obtain the necessary signatures. 4. Once signed, the District Manager will notify the Bookkeeper of the signatories, who will update the Check Control Log with their names or initials. 5. The Bookkeeper will verify the check and signatories once the check has cleared but before it is uploaded to the QuickBooks General Ledger. Anticipated Completion Date: June 30, 2025

View Audit 350779

Finding 541973 (2024-004)

Significant Deficiency 2024

United Tribes Technical College

ND

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Recommendation: We recommend the College follow and properly execute its procedures it has in place relating to non-payroll expenditures. Action Taken: The Finance department will review and ensure all journal entries are properly documented prior to making posting payments. Finance is 90% fully sta...

Recommendation: We recommend the College follow and properly execute its procedures it has in place relating to non-payroll expenditures. Action Taken: The Finance department will review and ensure all journal entries are properly documented prior to making posting payments. Finance is 90% fully staffed and new staff have been trained on how to do journal entries.

View Audit 350766 Questioned Costs: $1

Finding 541972 (2024-003)

Significant Deficiency 2024

United Tribes Technical College

ND

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Recommendation: We recommend the College follow and properly execute its procedures it has in place relating to payroll expenditures. Action Taken: The Finance department will review and ensure all payroll entries and payroll corrections are properly documented prior to making journal entries.

View Audit 350766 Questioned Costs: $1

Finding 541968 (2024-001)

Significant Deficiency 2024

Boston Public Health Commission

MA

Questioned Costs Allowable Costs / Cost Principles Cash Management

Management implemented an additional control that any submitted workbook or invoice that is changed by an awarding agency before payment is made, must be thoroughly reviewed and reconciled prior to authorizing the workbook or invoice for payment.

View Audit 350763 Questioned Costs: $1

Finding 541897 (2024-034)

Significant Deficiency 2024

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403

Mr. Waguespack: I am in receipt of the letter dated January 24, 2025 from Angel Cavaretta, Audit Manager, related to the misappropriation of research and development cluster funds. Louisiana Tech concurs with the recommendation. The misappropriation of funds occurred as a result of a sophisticate...

Mr. Waguespack: I am in receipt of the letter dated January 24, 2025 from Angel Cavaretta, Audit Manager, related to the misappropriation of research and development cluster funds. Louisiana Tech concurs with the recommendation. The misappropriation of funds occurred as a result of a sophisticated cyber fraud scheme in which perpetrators submitted fraudulent email requests directing that funds be deposited via electronic funds transfer (EFT) into accounts purportedly affiliated with the out-of-state University. However, the accounts were later discovered to have no connection to the institution. These deceptive actions exploited the University's payment processing systems and evaded detection at the time. Upon information a d belief, the data breach originated with the out-of-state University, and it is also noted that the out-of-state University did not detect discrepancies in its invoicing processes, including non-payment or fraudulent communications, which may have contributed to the fraud's success. Upon discovering the fraud, the University promptly reported the incident to appropriate law enforcement authorities, the Legislative Auditor, and the federal grantor. The University immediately reviewed all suppliers with an EFT payment type and has temporarily suspended the approval of any supplier requests related to the EFT payment option. As stated in the finding, the University is evaluating internal and external opportunities to further enhance its internal controls and verification procedures to better safeguard against increasingly sophisticated cyber threats targeting payment remittance processes.

View Audit 350759 Questioned Costs: $1

Finding 541887 (2024-026)

Significant Deficiency 2024

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles Eligibility

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 6, 2025 regarding a reportable audit finding related to Inadequate Internal Controls over Eligibility Determinations. LDH appreciates the ...

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 6, 2025 regarding a reportable audit finding related to Inadequate Internal Controls over Eligibility Determinations. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Internal Controls over Eligibility Determinations. Recommendation: LDH should ensure its employees follow procedure relating to eligibility determinations and redeterminations in the Medicaid and CHIP programs to ensure the case records support the eligibility decisions. LDH Response: LDH concurs in part with LLA’s finding of inadequate controls over eligibility determinations. For one Medicaid and five CHIP findings noted as the renewal not properly documented, LDH does not concur. LLA noted an error for a “SNAP” or “ELE” renewal documented as a “Streamlined” renewal. “SNAP”, “ELE”, and “Streamlined” renewals are all forms of an ex parte renewal per federal regulations at 42 CFR §435.916(b)(1) which requires the Medicaid agency to complete a renewal on the basis of information available to the agency without requiring information from the beneficiary. LDH uses these labels internally to identify what information or process used to complete the ex parte renewal. LDH presented documentation from system logs, which showed a system bug misidentified the ex parte process used but there was no error in the determination made. For one CHIP finding noted as inadequate documentation regarding income to support the renewal determination, LDH does not concur. The auditor cited a separate case in which a Medicaid analyst requested a written affidavit for the ending of self-employment income but not requested in this case. There is nothing in LDH policy or procedure that requires a written affidavit to verify ending of self-employment income. Corrective Actions: LDH already has a continual process of reviewing findings from internal case reviews, system bugs, appeal cases, external audits, or other sources then incorporating into policy/procedure updates, refresher trainings, reminder memos, and/or staff meetings. The findings from this audit will be added to this process. In addition, by April 1, 2025 Eligibility Program Operations will issue a summary of these findings to eligibility staff statewide reiterating the need to follow procedures and regulations relating to eligibility determinations to ensure the case records support the eligibility decisions. You may contact Kimberly Sullivan, Interim Medicaid Director at (225) 219-7810 or via e-mail at Kimberly.Sullivan@la.gov or Rhett Decoteau, Medicaid Section Chief at (225) 342-9044 or via email at Rhett.Decoteau@la.gov with any questions about this matter.

View Audit 350759 Questioned Costs: $1

Finding 541883 (2024-020)

Significant Deficiency 2024

State of Louisiana

LA

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

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) Child Welfare (CW) is in receipt of the audit findings identified as Control Weakness over SSBG Expenditures. DCFS concurs with the finding and is committed to minimizing errors and ensuring documentation practices support o...

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) Child Welfare (CW) is in receipt of the audit findings identified as Control Weakness over SSBG Expenditures. DCFS concurs with the finding and is committed to minimizing errors and ensuring documentation practices support our efforts for accuracy and compliance. DCFS will develop and implement training to ensure that instruction provided regarding the maintenance of TIPS records and payments will achieve compliance to the extent possible. DCFS CW Training and Foster Care will create a short refresher video course on policies and procedures relating to payment protocols to be made available to child welfare staff. The anticipated completion date will be June 30, 2025. Additionally, DCFS CW has adopted the use of DocuSign for TIPS forms which allows for a more streamlined process for signatures and supporting documentation to be uploaded. A short video course providing instruction on completing and submitting TIPS forms for reimbursement using the DocuSign platform is available to child welfare statewide. Management will reiterate staff to refer to this training. Should any additional information be required, please contact Renee M. Spell at (337) 250-1690 or Renee.Spell.DCFS@LA.GOV.

View Audit 350759

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