Corrective Action Plans

Finding 1156875 (2024-010)

Material Weakness 2024

State of Missouri

MO

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

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Health and Senior Services, Division of Senior and Disability Services Audit Finding Number: 2024-010 - Medicaid SPPC Participant Choice Agreements Name of the contact person responsible for co...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Health and Senior Services, Division of Senior and Disability Services Audit Finding Number: 2024-010 - Medicaid SPPC Participant Choice Agreements Name of the contact person responsible for corrective action: Kim Toebben, Deputy Director, Division of Senior and Disability Services Anticipated completion date for corrective action: May 2027 Missouri Department of Health and Senior Services agrees with the auditor’s recommendation. Corrective action planned is as follows: Division of Senior and Disability Services (DSDS) implemented a new electronic case management system, Fusion, in May 2025. As part of the upgraded efforts, the system will help to ensure more consistency with form retainment. This, however, will take some time due to challenges with data migration and staff adapting to the new workflow of the system. DSDS looks forward to improved compliance following the first full year of system implementation with a goal of full compliance by year 2 of system implementation.

View Audit 369219

Finding 1156874 (2024-006)

Material Weakness 2024

State of Missouri

MO

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Reporting

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services (DSS) – Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2024-006 - Department of Social Services Cost Allocation Name of the contact person responsi...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services (DSS) – Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2024-006 - Department of Social Services Cost Allocation Name of the contact person responsible for corrective action: Sheena Frazer Anticipated completion date for corrective action: N/A Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. DSS Response: The DSS partially agrees with this finding. The DSS agrees the logic used by OA-ITSD to generate the payroll extract report provided to DSS DFAS for import into the AlloCAP system did not include expenditures associated with Deferred Compensation Match Fringe (PDEFC) offered to state employees beginning in July 2022. It should be noted the PDEFC is not automatic or guaranteed and must be authorized and funded each year by the legislature during the budget process. FY23 was the first year in relative history the legislature authorized funding for PDEFC. The reason for the unchanged logic is unknown as staff transition occurred in both DSS and OA-ITSD during this time. The DSS respectfully disagrees with the finding and recommendation as represented and reported as an internal control finding related to cost allocation. The Internal Control Plan (ICP) clearly states the objectives related to the cost allocation plan and does not include oversight or reconciliation of source data provided to verify accuracy. Implementation of appropriate separation of duties and other internal control processes ensure SAMII data is not entered or maintained by the DFAS Grants Unit. As such, data integrity of SAMII and other source data provided by business units is not an internal control function within the ICP for cost allocation or the DFAS Grants Unit. Internal control findings for cost allocation should be relative to the approved objectives, data elements and processes outlined within the ICP for cost allocation or for which there is functional control. DSS DFAS continues to review internal control processes over the PACAP and AlloCap to ensure compliance with requirements and contends both were operating correctly as designed. This is evidenced as the finding did not result in any changes being required of the written PACAP or the programmed logic in AlloCap, only the raw data source provided which is not overseen or controlled by DFAS Grants Unit. It is for this reason the DSS partially agrees with the finding as the error is related to data integrity and not indicative of the strength of current internal controls for cost allocation. Corrective action planned is as follows: The DSS HRC and OA-ITSD have already identified the payroll tables and fields needed and revised the logic used to generate the payroll extract report to include Deferred Compensation Match Fringe (PDEFC). The DFAS Grants Unit utilized the revised payroll extract reports generated and provided to re-process the cost allocation system for the affected quarters in September and October 2024. As the DSS has already implemented the change, no further corrective action is required.

View Audit 369219

Finding 1156870 (2024-002)

Material Weakness 2024

State of Missouri

MO

Allowable Costs / Cost Principles Questioned Costs Eligibility

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2024-002 - Medicaid and CHIP Participant Eligibility Terminations Name of the contact...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2024-002 - Medicaid and CHIP Participant Eligibility Terminations Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: September 1, 2025 Recommendation: The DSS through the MHD and the FSD continue to review, strengthen, and enforce internal controls to ensure ineligible participant cases are closed when necessary and resume the DHSS vital records death match in the MEDES. DSS Response: The DSS partially agrees with this finding. DSS has controls in place to close coverage when a customer requests closure; however, the procedures were not followed. During the audit period, the FSD Call Center had processes in place to accept calls for applications, renewals, change in circumstance, enter evidence and inquiries. However, contracted staff are unable to authorize any action that results in a case closing and that authorization must be completed by a DSS employee. There were procedures in place for contracted staff to submit a form that will create a task for DSS staff to finalize the actions. For the case cited in the finding, the task was not created, resulting in DSS staff not receiving the request to voluntarily close the case. Although call center staff noted in the electronic case file the purpose of the call, there are not systematic controls in place to take action or create tasks for DSS employees from the case notes. Currently, a death match with Department of Health and Senior Services (DHSS) vital records is functional in the Family Assistance Management Information System (FAMIS) eligibility system currently used for Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and MO HealthNet for Aged, Blind, and Disabled (MHABD) individuals. When the match is received into FAMIS from DHSS, that information is included on the eligibility file submitted to the Medicaid Management Information System (MMIS) to ensure that the death date is captured in MMIS to prohibit any payments after the death of the individual. This control ensures that no improper payments are made on a beneficiary’s behalf after the date of death. DSS has processes in place to close eligibility when death information is received from family members and providers during the certification period. Additionally, in compliance with 42 CFR 435.949, DSS administers an electronic verification match with the federal hub at application and during the annual review process to inquire about death. DSS is continuing to evaluate necessary steps to reinstate the death match with DHSS vital records, but do not have an anticipated completion date. Regarding the questioned costs, eligibility errors are governed by section 1903(u) of the Social Security Act. Therefore, questioned costs identified in the single statewide audit should not be subject to recoupment. Corrective action planned is as follows: DSS is strengthening controls by revising the procedures of the contracted FSD Call Center to ensure case actions are completed timely. DSS will use a system action to close cases with out of state address evidence in the Missouri Eligibility and Enrollment System (MEDES).

View Audit 369219 Questioned Costs: $1

Finding 1156869 (2024-001)

Material Weakness 2024

State of Missouri

MO

Allowable Costs / Cost Principles Eligibility

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services – Family Support Division Audit Finding Number: 2024-001 – Medicaid and CHIP MAGI-Based Participant Eligibility Redeterminations Name of the contact person responsible for corre...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services – Family Support Division Audit Finding Number: 2024-001 – Medicaid and CHIP MAGI-Based Participant Eligibility Redeterminations Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: N/A Recommendation: The DSS through the MHD and the FSD continue to review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. DSS Response: The DSS disagrees with this finding. The DSS disagrees there is a significant deficiency in internal controls. As noted in the finding, from the 60 participants selected, the SAO did not identify any participants with previously-established overrides; therefore, no incorrect payments were cited. Section 6008 of the Families First Coronavirus Response Act (FFCRA) required states to provide continuous coverage, through the end of the month in which the PHE period ends, to all Medicaid beneficiaries who were enrolled in Medicaid on or after March 18, 2020, regardless of any changes in eligibility unless the individual voluntarily terminated eligibility, is deceased, or moved out of state. As required by the Centers for Medicaid and Medicare Services (CMS) during the PHE, the DSS had processes in place to terminate eligibility for individuals who were deceased, voluntarily requested closure, or reported they have moved out of state when a current change was reported. The Consolidated Appropriations Act, 2023, signed on December 29, 2022, amended section 6008 of the FFCRA such that the continuous enrollment condition ended on March 31, 2023. During the PHE, the DSS did not conduct reviews of cases that did not report current changes. DSS resumed initiating renewals starting in April 2023 under the unwinding plan submitted to CMS with the goal to complete all unwinding related renewals prior to the deadline of August 31, 2024. However, DSS encountered challenges in completing all unwinding renewals by the established deadline. On August 29, 2024, CMS released guidance recognizing the challenges that many states faced impacting the ability to complete unwinding related renewals and restore routine operations within the original timelines established, extending the allowance for states to continue to use the exception under 42 CFR 435.912(e) through December 31, 2025. A report identifying all individuals with manual overrides was created in August 2023 to ensure that individuals with determinations created outside of the MEDES system are being renewed timely. The DSS continues to work this report monthly. DSS staff are working to complete renewals on participants included on the report that require an annual renewal. DSS will complete redeterminations on all cases with manual overrides that have had continuous coverage for over one year by July 31, 2025. DSS notes that not all cases with manual overrides have had continuous coverage for more than one year and therefore do not currently require a redetermination. DSS will complete redeterminations on these cases when they become due. DSS will continue to use this report to ensure that all individuals that receive coverage outside of the MEDES system will receive their annual renewal as required by CFR 435.916.

View Audit 369219

Finding 1156844 (2024-013)

Material Weakness 2024

State of Missouri

MO

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

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2424-013 - Child Care Payments Name of the contact person responsible for corrective action: Shelley Woods Anticipated completion...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2424-013 - Child Care Payments Name of the contact person responsible for corrective action: Shelley Woods Anticipated completion date for corrective action: 12/31/2025 Corrective action planned is as follows: DESE agrees with the auditor's finding. DESE is working on strengthening internal controls within the Child Care Data System (CCDS) to prevent duplicate payments and overpayments due to absences and attendance and ensure sliding fees for each child are correct. DESE has worked with the Administration for Children and Families on the specific requirements related to correcting overpayments. DESE has paid the providers with underpayments.

View Audit 369219 Questioned Costs: $1

Finding 1156828 (2024-008)

Material Weakness 2024

State of Missouri

MO

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

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Health and Senior Services (DHSS) Audit Finding Number: 2024-008 - CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Ant...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Health and Senior Services (DHSS) Audit Finding Number: 2024-008 - CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: Corrective action planned is as follows: The agency does not agree with the audit findings and therefore no corrective action is required. Explanation and specific reasons are as follows: Department of Health and Senior Services (DHSS) disagrees with this finding because the previous audit finding in the FY2023 SWSA was not sustained by the federal funding agency, therefore no finding or corrective action is required.

View Audit 369219 Questioned Costs: $1

Finding 1156820 (2024-001)

Material Weakness 2024

Women for Afghan Women, INC

NY

Allowable Costs / Cost Principles

We will ensure to follow recommendations and be compliant with time allocation requirements. Effective January 2025, WAW transitioned to a new HR and payroll system that addressed this finding, also incorporated periodic review and reconciliation. This change strengthens compliance with 2 CFR 200.43...

We will ensure to follow recommendations and be compliant with time allocation requirements. Effective January 2025, WAW transitioned to a new HR and payroll system that addressed this finding, also incorporated periodic review and reconciliation. This change strengthens compliance with 2 CFR 200.430, which requires that charges to federal awards for salaries and wages be supported by records that accurately reflect the work performed. We also note that during 2024, while timesheet hours were not directly used for reallocating salary costs, WAW had in place a monthly reconciliation process. This included comparing monthly budgeted allocations to total actual expenses and tracking all expenditures to help ensure costs remained reasonable, allocable, and allowable.

View Audit 369210

Finding 1156812 (2024-003)

Material Weakness 2024

Florence County

WI

Questioned Costs Allowable Costs / Cost Principles Cash Management

DEPARTMENT OF TREASURY 2024-003 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: We recommend that there is an appropriate reviewer of journal entry. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actio...

DEPARTMENT OF TREASURY 2024-003 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: We recommend that there is an appropriate reviewer of journal entry. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The amounts reported were accurate and in compliance. The department will continue to train employees in respective positions to ensure responsibilities align with program requirements. Immediately upon discovery of the omission of the review step, management reiterated to department financial staff the importance of the review process. Name(s) of the contact person(s) responsible for corrective action: Kim Merrill, Finance Manager Planned completion date for corrective action plan: December 31, 2025

View Audit 369191

Finding 1156788 (2024-002)

Material Weakness 2024

Mississippi Public Health Institute

MS

Allowable Costs / Cost Principles Questioned Costs Cash Management

AUDITEE’S CORRECTIVE ACTION PLAN As required by 2CFR Section 200.511 of the Uniform Guidance, Mississippi Public Health Institute has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questions Costs for the year ended December...

AUDITEE’S CORRECTIVE ACTION PLAN As required by 2CFR Section 200.511 of the Uniform Guidance, Mississippi Public Health Institute has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questions Costs for the year ended December 31, 2024: Federal Award Findings and Questioned Costs 2024-002 Unallowable Costs Criteria - The Uniform Guidance states that any federal share of allowable costs must be refunded to the government. During our audit, we noticed an instance of duplicate expenditures being recorded. Reimbursement was requested and received for these costs from the Racial and Ethnic Approaches to Community Health program under ALN 93.304. This occurred through a single vendor, for which it was noted that the vendor had sent duplicate invoices, and MSPHI recorded both invoices. Recommendation - We recommend the implementation of IT controls to prevent duplicate invoice numbers to be recorded. Corrective Action Plan - Mississippi Public Health Institute will increase oversight of grant expenditures and drawdowns to improve reconciliation accuracy. Position of Responsible Official – John Davis, Chief Financial Officer Anticipated Completion Date – Completed after brought to client’s attention. August 31st, 2025.

View Audit 369168 Questioned Costs: $1

Finding 1156787 (2024-001)

Material Weakness 2024

Cat Spring Volunteer Fire Department

TX

Allowable Costs / Cost Principles

The Department will establish procurement policies and procedures to include federal contract provisions and will establish and adopt written policies for federal awards.

View Audit 369157

Finding 1156782 (2024-003)

Material Weakness 2024

Idaho Coalition Against Sexual & Domestic Violence, Inc.

ID

Allowable Costs / Cost Principles § 200.514 § 200.514(C)

THE IDAHO COALITION WILL IMPLEMENT STRENGTHENED INTERNAL CONTROLS OVER THE ALLOCATION OF NON-PAYROLL EXPENSES TO FEDERAL PROGRAMS, CONSISTENT WITH 2 C.F.R. PART 200 AND THE DOJ GRANTS FINANCIAL GUIDE. SPECIFICALLY, THE ORGANIZATION WILL: 1. DOCUMENT ALLOCATION METHODOLOGY: ESTABLISH AND MAINTAIN WRI...

THE IDAHO COALITION WILL IMPLEMENT STRENGTHENED INTERNAL CONTROLS OVER THE ALLOCATION OF NON-PAYROLL EXPENSES TO FEDERAL PROGRAMS, CONSISTENT WITH 2 C.F.R. PART 200 AND THE DOJ GRANTS FINANCIAL GUIDE. SPECIFICALLY, THE ORGANIZATION WILL: 1. DOCUMENT ALLOCATION METHODOLOGY: ESTABLISH AND MAINTAIN WRITTEN PROCEDURES THAT CLEARLY DESCRIBE THE ALLOCATION METHODOLOGY FOR NON-PAYROLL EXPENSES, ENSURING COSTS ARE 1402 W GROVE STREET BOISE, IDAHO 83702 WWW.IDAHOCOALITION.ORG ALLOWABLE, REASONABLE, AND ALLOCABLE TO EACH FEDERAL AWARD. 2. APPROVAL & REVIEW: REQUIRE CONTEMPORANEOUS REVIEW AND APPROVAL OF ALL NON-PAYROLL ALLOCATION JOURNAL ENTRIES BY THE FINANCE STEWARD (OR DESIGNATED FINANCE STAFF) AND THE EXECUTIVE DIRECTOR. 3. SUPPORTING DOCUMENTATION: MAINTAIN SOURCE DOCUMENTATION (E.G., INVOICES, ALLOCATION SCHEDULES, APPROVAL RECORDS) IN THE FINANCIAL SYSTEM TO DEMONSTRATE COMPLIANCE WITH UNIFORM GUIDANCE STANDARDS. 4. QUARTERLY MONITORING: CONDUCT QUARTERLY RECONCILIATIONS OF ALLOCATIONS TO ENSURE COMPLIANCE WITH FEDERAL COST PRINCIPLES. 5. TRAINING: PROVIDE TRAINING TO FINANCE STAFF AND MANAGERS ON ALLOWABLE COST REQUIREMENTS UNDER 2 C.F.R. § 200.403–405 AND OVW/HHS AWARD CONDITIONS TO REINFORCE COMPLIANCE.

View Audit 369122

Finding 1156777 (2024-003)

Material Weakness 2024

Special Children's Charities

IL

Questioned Costs Reporting Subrecipient Monitoring § 200.302

The audit noted that federal awards and expenditures were not adequately tracked by grant in the general ledger. Corrective action has already been taken: the general ledger has been updated to ensure that federal awards are now tracked by the grant program. This enhancement allows for improved acco...

The audit noted that federal awards and expenditures were not adequately tracked by grant in the general ledger. Corrective action has already been taken: the general ledger has been updated to ensure that federal awards are now tracked by the grant program. This enhancement allows for improved accountability, accurate reporting, and compliance with federal requirements.

View Audit 369106

Finding 1156771 (2024-006)

Material Weakness 2024

Sacramento Housing and Revelopment Agency

CA

Special Tests & Provisions Questioned Costs Subrecipient Monitoring

Emergency Solutions Grants Program – Assistance Listing No. 14. 231 Recommendation: We recommend that management ensure that internal controls are in place to ensure subrecipient payments are paid timely and within program requirements. Explanation of disagreement with audit finding: There is no dis...

Emergency Solutions Grants Program – Assistance Listing No. 14. 231 Recommendation: We recommend that management ensure that internal controls are in place to ensure subrecipient payments are paid timely and within program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent recurrence, the following actions will be taken: - All future ESG contracts will be directly managed by the ESG Program Manager and Program Analyst, ensuring appropriate oversight and compliance with program requirements. - All program analysts will be retrained on invoice processing requirements. - The Program manager will evaluate the potential use of an online system for receiving and tracking invoices. Name(s) of the contact person(s) responsible for corrective action: Stephanie Green, Program Manager Planned completion date for corrective action plan: January 01, 2026

View Audit 369097

Finding 1156752 (2024-001)

Material Weakness 2024

Plumas-Sierra Rural Electric Cooperative

CA

Questioned Costs Allowable Costs / Cost Principles § 200.430

Management understands that CFR 200.430 requires compensation for personnel services to be based on records that accurately reflect the work performed, and costs must be properly allocated to benefiting programs or cost objectives. The HR/Payroll Administrator has implemented a review process to ens...

Management understands that CFR 200.430 requires compensation for personnel services to be based on records that accurately reflect the work performed, and costs must be properly allocated to benefiting programs or cost objectives. The HR/Payroll Administrator has implemented a review process to ensure that all payroll changes are properly reviewed, verified, and approved prior to final payroll processing and the Cooperative does not believe this should be in an issue going forward.

View Audit 369091 Questioned Costs: $1

Finding 1156733 (2024-001)

Material Weakness 2024

Oakland Livingston Human Service Agency

MI

Allowable Costs / Cost Principles Period of Performance Questioned Costs § 200.308 § 200.403

The Agency agrees with the finding. We will provide training to program managers who are approving program expenditures to ensure proper allocation of costs to the appropriate grant cycles. We will also update our purchasing procedures to ensure that the proper allocation of costs is reviewed prior ...

The Agency agrees with the finding. We will provide training to program managers who are approving program expenditures to ensure proper allocation of costs to the appropriate grant cycles. We will also update our purchasing procedures to ensure that the proper allocation of costs is reviewed prior to supervisor's approval of the cost.

View Audit 369077

Finding 1156726 (2024-003)

Material Weakness 2024

Amsterdam Housing Authority

NY

HUD Housing Programs Questioned Costs Subrecipient Monitoring

Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (...

Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (3) Finding 2024-003 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for additional comments and action taken. (b) Action taken - The Authority will establish internal tracking and reminder systems to ensure all required reports, including the final P&E and AMCC, are completed and submitted to HUD by the required due dates. Grant reporting responsibilities will be clearly assigned, and submission deadlines will be monitored by the Director of Finance to prevent future delays. These procedures will be implemented immediately. (c) Planned implementation date - The Authority plans to implement procedures during the year ending December 31, 2025 to resolve the reported finding.

View Audit 369074

Finding 1156720 (2024-001)

Material Weakness 2024

Norton Healthcare, Inc. and Affiliates

KY

Allowable Costs / Cost Principles

Finding 2024-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Assistance Listing No: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially D...

Finding 2024-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Assistance Listing No: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period: January 1, 2024 through December 31, 2024 Summary of finding: A material weakness in internal control over compliance was issued related to activities allowed or unallowed for the COVID-19 Disaster Grants – Public Assistance of Norton Healthcare, Inc. and Affiliates (the Corporation). While Management designed internal controls that required expenditures to be reviewed by members of the respective departments in which they originated (e.g. payroll and accounts payable) as expenditures were incurred, internal controls were not designed or implemented around the accumulation of expenditures and review of such expenditures for allowability under the projects for which Norton was approved under the COVID-19 Disaster Grants. Furthermore, the Company does not have formalized policies or documentation around internal contract agency travel allowances, and the payroll department did not retain documentation to evidence the function’s review of unapproved timesheets. Planned corrective action: Norton Healthcare is currently upgrading its timekeeping and attendance system. As part of this initiative, enhanced training and expanded functionality for timekeepers will help ensure that timecards are reviewed and approved prior to payment, in compliance with internal requirements. Relevant policies and procedures will be updated to support this process, including the retention of appropriate documentation. Additionally, the Norton Clinical Agency will establish a formal written policy outlining the stipend review and approval process, ensuring that all documentation is properly maintained. All other expenses submitted to FEMA will be reviewed and approved in writing, outside of the Grants Portal, with appropriate documentation. At this time, there are no pending or anticipated projects related to FEMA claims. Anticipated completion date: December 31, 2026 Responsible contact person: Adam Kempf

View Audit 369066

Finding 1156714 (2024-003)

Material Weakness 2024

Advocate Aurora Health, Inc.

IL

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

Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were ...

Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were completed for all individuals working on multiple federal programs. Management Response: To address the identified deficiency, management is introducing standardized procedures to ensure that effort certifications are completed accurately and on time for all program staff. Program staff will receive targeted training, and a monitoring process will be implemented to support ongoing reviews. In addition, improvements to the effort tracking methodology are being considered to enhance the accuracy of employee time reporting across multiple federal grants, thereby strengthening compliance and minimizing the risk of reporting errors. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director, Venice Northe, Grants Accounting Manager and Program teams. Anticipated Completion Date: December 31, 2025.

View Audit 369065

Finding 1156697 (2024-002)

Material Weakness 2024

Advocate Aurora Health, Inc.

IL

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

Finding 2024-002 Crime Victim Assistance (ALN 16.575) The Organization has internal controls in place to ensure employees’ effort certifications are approved. However, the Organization did not have internal controls to ensure that allchanges in employees’ certified effort were communicated, recorded...

Finding 2024-002 Crime Victim Assistance (ALN 16.575) The Organization has internal controls in place to ensure employees’ effort certifications are approved. However, the Organization did not have internal controls to ensure that allchanges in employees’ certified effort were communicated, recorded and charged to the grant. Management Response: Management will develop and implement written procedures to ensure the timely communication of discrepancies identified during the effort certification process to the Grant Accounting team for appropriate review and adjustment. Program staff will be trained in the new process, and reviews will be conducted to monitor compliance and ensure the continued effectiveness of the process. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director and Venice Northe, Grants Accounting Manager. Anticipated Completion Date: December 31, 2025.

View Audit 369065

Finding 1156687 (2024-004)

Material Weakness 2024

Madonna Center, Inc.

TX

Questioned Costs Allowable Costs / Cost Principles

Management agrees and will develop review procedures to respond to the findings.

View Audit 369054 Questioned Costs: $1

Finding 1156685 (2024-002)

Material Weakness 2024

Madonna Center, Inc.

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Management agrees and will develop review procedures to respond to the findings.

View Audit 369054 Questioned Costs: $1

Finding 1156684 (2024-001)

Material Weakness 2024

Madonna Center, Inc.

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.430

Management agrees with the finding and will work with the City of San Antonio to correct the issue, and develop review procedures to respond to the finding.

View Audit 369054 Questioned Costs: $1

Finding 1156679 (2024-002)

Material Weakness 2024

Employment Connection

MO

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Corrective Action Plan: Strengthen detailed process for review over payroll charges billed to federal programs. To address the significant deficiency over allowable costs identified in the Single Audit, the Organization will enhance its existing review procedures by implementing a more detailed mont...

Corrective Action Plan: Strengthen detailed process for review over payroll charges billed to federal programs. To address the significant deficiency over allowable costs identified in the Single Audit, the Organization will enhance its existing review procedures by implementing a more detailed monthly review process. This will include verifying payroll charges against supporting documentation such as payroll registers, time records, and allocation spreadsheets. Management will also explore the development of a standardized reconciliation checklist and introduce a secondary review step to ensure accuracy and completeness. These measures, combined with continued monthly oversight by the CFO, are intended to reduce the risk of billing errors due to human oversight and reinforce the reliability of payroll cost allocations. Name of Responsible Person: Nora Davis, Chief Financial Officer Anticipated Completion Date: April 30, 2026

View Audit 369034

Finding 1156668 (2024-003)

Material Weakness 2024

Belmont County

OH

Allowable Costs / Cost Principles Questioned Costs Cash Management § 200.405

Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interp...

Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interpretation. As a result of this finding, BCDJFS will reassign the FCFC Coordinator to the shared cost pool and reimburse the shared cost pool from the applicable FCFC allocations through a MOU signed between the council and BCDJFS

View Audit 369030 Questioned Costs: $1

Finding 1156667 (2024-006)

Material Weakness 2024

Adams County

OH

Student Financial Aid Allowable Costs / Cost Principles § 200.302

The Children Service Department will seek legal advice on the implementation of a policy that meets the requirements set for in 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles.

View Audit 369025

Corrective Action Plans

Filters