Corrective Action Plans

Finding 554611 (2024-017)

Significant Deficiency 2024

State of Oregon

OR

Special Tests & Provisions Eligibility Significant Deficiency § 200.303

2024-017 Oregon Department of Human Services/Oregon Health Authority Strengthen internal controls over the ONE system Management Response: We agree with this recommendation. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in...

2024-017 Oregon Department of Human Services/Oregon Health Authority Strengthen internal controls over the ONE system Management Response: We agree with this recommendation. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in 2025. Additionally, ODHS will work on amending the ONE M&O agreement with Deloitte for them to obtain a scoped SOC 2 Type II audit related to their work within the ONE system. ODHS would expect to negotiate this additional audit requirement in 2025 with the first audit then happening in 2026. In addition, the agency will request reports that will allow reconciliation of transactions between ONE and the mainframe system. Anticipated Completion Date: December 31, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353285

Finding 554607 (2024-013)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Significant Deficiency Internal Control / Segregation of Duties

2024-013 Oregon Health Authority Improve documentation and controls over client eligibility Management Response: We agree with this recommendation. A specific case was discovered where the state failed to obtain a signature from an SSI individual. Due to the individual’s SSI status and being continu...

2024-013 Oregon Health Authority Improve documentation and controls over client eligibility Management Response: We agree with this recommendation. A specific case was discovered where the state failed to obtain a signature from an SSI individual. Due to the individual’s SSI status and being continuously on benefits, the ONE system attempts to passively approve renewals without requiring worker interaction, leading to potential gaps where signatures are not on file for cases that converted into the new system in 2020 and 2021. The operation lapse occurred because the SSI individual converted into the new system on continuous benefits going through passive renewal processes that do not require direct worker interaction. The State of Oregon is working with the local branch to obtain a verbal signature from the identified individual. Additionally, the State conducted a thorough review of current policies and procedures related to passive renewals for SSI individuals to ensure compliance with federal requirements. • Call center software recordings and verbal signatures has been updated as recently as February 2025 providing staff with clear direction on how to capture the verbal signatures and which recordings to play. • Establishing DOR/Filing Date Eligibility Guide was updated as recently as March 13, 2025, including a chart itemizing the signature types (electronic and paper forms), programs that accept each type, and the corresponding option to select in ONE • Rights and Responsibilities Eligibility Guide was enhanced on Oct. 7, 2024 to add detailed directions to staff on how to capture the signature in ONE, when rights and responsibilities are not issued automatically, the appropriate Rights and Responsibilities to provide for each program and where to find a current signature record on file. • Finally, the Case Action Eligibility Guide has been updated to include specific guidance and examples of when it's appropriate to extend processing timeframes for RFI's. Anticipated Completion Date: May 1, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353285

Finding 554605 (2024-011)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Period of Performance Significant Deficiency § 200.303

2024-011 Oregon Health Authority Strengthen existing controls to ensure only those costs incurred during the period of performance are charged to the grant Management Response: The agency agrees with the finding. While the appropriate internal controls are in place to review the period of performan...

2024-011 Oregon Health Authority Strengthen existing controls to ensure only those costs incurred during the period of performance are charged to the grant Management Response: The agency agrees with the finding. While the appropriate internal controls are in place to review the period of performance, a mistake was made while following the procedures. Secondary reviews will be performed going forward to ensure all expenditures are appropriately captured. The expenditures in question were moved to the correct phase 22 on Jan. 23, 2025 with document BTCG3186. Anticipated Completion Date: January 23, 2025 Contact Person: Travis Labrum, Accounting Manager

View Audit 353285 Questioned Costs: $1

Finding 554598 (2024-010)

Significant Deficiency 2024

State of Oregon

OR

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

2024-010 Oregon Health Authority Submit required Federal Funding Accountability and Transparency Act reports Management Response: The agency agrees with the finding. The FFATA Reporting Coordinator position within the Office of Contracts & Procurement (OC&P) has been vacant for eight months but sho...

2024-010 Oregon Health Authority Submit required Federal Funding Accountability and Transparency Act reports Management Response: The agency agrees with the finding. The FFATA Reporting Coordinator position within the Office of Contracts & Procurement (OC&P) has been vacant for eight months but should be filled by April 15, 2025. On March 8, 2025, FSRS.gov was retired, and all subaward reporting data and functionality are now on SAM.gov. The new SAM.gov reporting system will allow for multiple Data Entry roles, allowing each program or division of ODHS/OHA to submit their own reporting, and allowing OC&P to conduct Quality Assurance/Quality Control. Once the FFATA Reporting Coordinator is onboard and trained, we anticipate the FFATA reporting will resume and any missing reports will be submitted by April 15, 2026. Anticipated Completion Date: April 15, 2026 Contact person: Noemi Schlegel, Compliance & Audits Program Manager

View Audit 353285

Finding 554593 (2024-025)

Significant Deficiency 2024

State of Oregon

OR

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

2024-025 Oregon Department of Human Services Ensure work participation rate calculation uses verified and accurate data Management Response: We agree with this recommendation. Office of Program Integrity’s leadership priorities are to update the risk assessment and to continue to meet weekly with th...

2024-025 Oregon Department of Human Services Ensure work participation rate calculation uses verified and accurate data Management Response: We agree with this recommendation. Office of Program Integrity’s leadership priorities are to update the risk assessment and to continue to meet weekly with the Chief Operating Officer to highlight the risks associated with inadequate staffing levels. Risk mitigation efforts to ensure JOBS reviews are performed in accordance with established procedures include cross training JOBS second level Quality Control beginning in March 2025 and time studies planned to determine adequate staffing levels for additional position requests. ODHS has a current workgroup led by the Project Management Office (PMO) that is tasked with conducting a training and coaching gap analysis for family coaches and making recommendations regarding Oregon’s Work Participation Rate. The workgroup consists of TANF policy analysts and the self- sufficiency training unit. In addition to the gap analysis, the workgroup is currently producing communications regarding documentation of work participation hours. ODHS will implement additional recommendations once they are identified. Anticipated Completion Date: 12/31/2025 Contact Person: Eva Ruiz, TANF program manager

View Audit 353285

Finding 554590 (2024-022)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Special Tests & Provisions Eligibility § 200.303

2024-022 Oregon Department of Human Services Improve controls to ensure eligibility criteria are met Management Response: We agree with this recommendation. Beginning in April 2025 the Quality Control (QC) manager will have oversight of the process and be included in the emails between the QC lead a...

2024-022 Oregon Department of Human Services Improve controls to ensure eligibility criteria are met Management Response: We agree with this recommendation. Beginning in April 2025 the Quality Control (QC) manager will have oversight of the process and be included in the emails between the QC lead and administration concerning the error packets being sent to the branch for corrective action by the 15th of each month. The QC manager will check on the 16th of each month to ensure the task was completed. Department management acknowledges the finding and has already initiated actions to address the concerns. The State of Oregon has implemented a structured approach to address this concern. Since January 2025, the Oregon Eligibility Partnership (OEP) has updated and developed six eligibility guides aimed at improving, understanding, and execution of processes related to TANF enrollment, including asset pursuit and IEVS checks. These guides are now available as part of the training curriculum for eligibility workers. Additionally, the "Verification Take Time for Training" (TT4T) module, which was last presented in October 2022, will be reviewed by the OEP to assess potential gaps or outdated information. Any necessary updates will be incorporated by July 2025 to ensure comprehensive training is available to all eligibility workers. Finally, OEP will continue to monitor the effectiveness of the updated training materials and guides through ongoing reviews, feedback collection from eligibility workers, and periodic review and refreshing of the materials. Anticipated Completion Date: December 31, 2025 Contact Person: Eva Ruiz, TANF program manager

View Audit 353285 Questioned Costs: $1

Finding 554589 (2024-021)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Reporting Significant Deficiency

2024-021 Oregon Department of Human Services Obtain accurate information from the ONE application Management Response: We agree with this recommendation. ODHS will continue to monitor and review the ACF-199 and ACF-209 prior to submission. The review will include a sample of JOBS eligible individual...

2024-021 Oregon Department of Human Services Obtain accurate information from the ONE application Management Response: We agree with this recommendation. ODHS will continue to monitor and review the ACF-199 and ACF-209 prior to submission. The review will include a sample of JOBS eligible individuals who do not have countable work activities in the ACF reports, to confirm that their TRACS personal development plan (PDP) accurately reflects engagement and activities in which the individual is engaged. Additionally, ODHS will implement a tracking system to ensure the review of reports is clearly documented. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in 2025. Additionally, ODHS will work on amending the ONE Maintenance & Operations agreement with Deloitte for them to obtain a scoped SOC 2 Type II audit related to their work within the ONE system. ODHS would expect to negotiate this additional audit requirement in 2025 with the first audit then happening in 2026. Anticipated Completion Date: December 31, 2025 Contact Person: Eva Ruiz, TANF program manager

View Audit 353285

Finding 554587 (2024-029)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Period of Performance Reporting

2024-029 Oregon Commission for the Blind Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with the recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate, and to ensuring the agency’s case m...

2024-029 Oregon Commission for the Blind Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with the recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate, and to ensuring the agency’s case management system is well-documented and current. This issue was initially identified during the statewide single audit for the period ended June 30, 2023. In response to the prior year’s finding, the agency created a new case-note category for documenting client employment start date and wages at exit. Compliance with this new control is then verified as part of our pre-closure case file review process. The agency will continue to provide training to staff on the use of this case note category to ensure we are consistently documenting the start date of employment in the primary occupation and the hourly wage at exit. Anticipated Completion Date: July 1, 2025 Contact person: Angel Hale, Director of Vocational Rehabilitation Services

View Audit 353285

Finding 554586 (2024-028)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Period of Performance Reporting

2024-028 Oregon Department of Human Services Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with this recommendation. We agree with the recommendation and will ensure adequate supporting documentation is maintained and readily available to ...

2024-028 Oregon Department of Human Services Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with this recommendation. We agree with the recommendation and will ensure adequate supporting documentation is maintained and readily available to support information reported in the RSA-911. We will update internal controls related to this matter. Anticipated Completion Date: September 30, 2024 Contact Person: Bryan Campbell, Vocational Rehabilitation Operations Manager

View Audit 353285

Finding 554585 (2024-043)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Internal Control / Segregation of Duties § 200.303

2024-043 Department of Veterans' Affairs Encourage accuracy of per diem recalculations Management Response: ODVA agrees with this recommendation Reconciliation/recalculation procedures have been updated to fully align with regulations as established by 38 CFR 51.40. These procedures will include cal...

2024-043 Department of Veterans' Affairs Encourage accuracy of per diem recalculations Management Response: ODVA agrees with this recommendation Reconciliation/recalculation procedures have been updated to fully align with regulations as established by 38 CFR 51.40. These procedures will include calculation of days when a veteran may be absent for purposes other than receiving hospital care. In addition to strengthening procedures, the controller will review the reconciliation each month. Anticipated Completion Date: June 30, 2025 Contact person: Nicole Dolan, Budget and Fiscal Manager

View Audit 353285

Finding 554584 (2024-038)

Significant Deficiency 2024

State of Oregon

OR

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

2024-038 Oregon Business Development Department Implement controls over reporting Management Response: We agree with this recommendation. The submission of the quarterly financial reports by Business Oregon to DAS CFRT is on-going and within the submission deadline of DAS CFRT staff. When preparing ...

2024-038 Oregon Business Development Department Implement controls over reporting Management Response: We agree with this recommendation. The submission of the quarterly financial reports by Business Oregon to DAS CFRT is on-going and within the submission deadline of DAS CFRT staff. When preparing for the quarterly financial report, the accounting/financial data has been prepared by our accountant and reviewed by Business Oregon’s accounting manager. The data is then submitted to program staff to complete the programmatic narrative and other performance-related information to further explain or describe the transactions for the reporting period, and then program staff submits the quarterly report to DAS CFRT. Going forward, to ensure reports submitted to DAS CFRT match with accounting records, management will make procedure changes by routing the report back to the accounting team for final review of financial data after program has entered their part of the report before sending to DAS CFRT. We will implement this process change effective immediately for the quarterly report ending March 2025. For the cumulative variance of $1.6 million, Business Oregon will conduct research to determine the cause of the variance. The under-reporting of expenses on the quarterly report ending June 2024 could be the result of data provided to DAS in mid-July 2024, to meet DAS CFRT reporting deadline, when the fiscal month of June 2024 was not officially closed until early August 2024. While the fiscal year-end process was still on-going through August 2024, the month of June is still open for accrual entries or adjustments, resulting to more expenditures in accounting records than what was reported to DAS in July. Business Oregon will perform reconciliation of data from 2020 to March 2025 to true up the expenditures reported in the accounting records and the reports submitted to DAS CFRT. Anticipated Completion Date: March 31, 2025 Contact person: Imee Anderson, Chief Financial Officer, Mia Seo, Deputy-Chief Financial Officer, Rory Spencer, Accounting Manager

View Audit 353285

Finding 554576 (2024-041)

Significant Deficiency 2024

State of Oregon

OR

Period of Performance Significant Deficiency Internal Control / Segregation of Duties

2024-041 Oregon Military Department Ensure undisbursed obligation extension support is retained Management Response: We agree with this recommendation. The Oregon Military Department (OMD) acknowledges the finding related to the retention of support for undisbursed obligation extensions. We recogniz...

2024-041 Oregon Military Department Ensure undisbursed obligation extension support is retained Management Response: We agree with this recommendation. The Oregon Military Department (OMD) acknowledges the finding related to the retention of support for undisbursed obligation extensions. We recognize the importance of maintaining documentation to support the extensions of General Terms and Conditions (GTC) Cooperative Agreement (CA) Awards to ensure compliance with federal regulations and avoid potential funding risks. OMD will implement following corrective actions to address the recommendation made in the Audit Report. • Standardized Documentation Process: We will develop and implement a standardized process for tracking and retaining all submitted GTA CA Award extensions, including detailed listings of un-cleared obligations and projected liquidation timelines. • Internal Review and Monitoring: A designated team within the finance division will conduct quarterly reviews of undisbursed obligations to ensure compliance with extension requirements. • Training and Accountability: Training will be provided to relevant personnel on the importance of documentation retention, compliance requirements, and the consequences of noncompliance. Management will also assign accountability measures to track adherence to the new procedures. Anticipated completion date: June 30, 2025. Contact person: Adam Giblin, Chief Financial Officer.

View Audit 353285

Finding 554575 (2024-031)

Significant Deficiency 2024

State of Oregon

OR

Subrecipient Monitoring Reporting School Nutrition Programs § 200.303

2024-031 Department of Education Implement controls to ensure FFATA reporting is completed for all required subawards Management Response: ODE agrees with this finding. To strengthen controls and ensure FFATA reporting is completed for all required subawards, ODE plans to implement the following pro...

2024-031 Department of Education Implement controls to ensure FFATA reporting is completed for all required subawards Management Response: ODE agrees with this finding. To strengthen controls and ensure FFATA reporting is completed for all required subawards, ODE plans to implement the following process improvements: • Collaborate with the Child Nutrition program management and Fiscal Grants team to provide full documentation of grant awards including terms, conditions and attachments. • Update ODE’s grant profile request Smartsheet tool to: o Identify FFATA eligibility prior to setting up a new grant award in the accounting system. o Automatically notify the FFATA team of new grant awards that require reporting. Anticipated Completion Date: June 30, 2025 Contact person: Kristie Miller, Accounting Director

View Audit 353285

Finding 554574 (2024-002)

Significant Deficiency 2024

Okc Charter Santa Fe South Schools No. G-021

OK

Equipment & Real Property Management Procurement, Suspension & Debarment Significant Deficiency § 200.313

Amend the property records invenotry procedures to follow 2 CFR Section 200.313 (3 through (2); see the criteria of the finding for the detailed list of requirements.

View Audit 353277

Finding 554573 (2024-004)

Material Weakness 2024

Meade County Water District

KY

Internal Control / Segregation of Duties § 200.510

Recommendation noted. Staff has requested a quote from our QuickBooks advisor, Kemper CPAs.

View Audit 353274

Finding 554541 (2024-004)

Significant Deficiency 2024

Falmouth Housing Authority

MA

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

2024-004 - REPORTING Significant Deficiency Auditee’s Response and Planned Corrective Action As with 2024-001, this finding was based on a HUD system error that prevented submission on the due date. FHA experienced transition in the fiscal department and is cross-training backup personnel. A 10-day ...

2024-004 - REPORTING Significant Deficiency Auditee’s Response and Planned Corrective Action As with 2024-001, this finding was based on a HUD system error that prevented submission on the due date. FHA experienced transition in the fiscal department and is cross-training backup personnel. A 10-day buffer will be applied internally to submission deadlines to ensure on-time filing regardless of staff changes and absences. Planned Implementation Date of Corrective Action: Immediate Person Responsible for Corrective Action: Bobbi Richards, Executive Director

View Audit 353264

Finding 554540 (2024-002)

Significant Deficiency 2024

Falmouth Housing Authority

MA

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

2024-002 – INTERNAL CONTROLS OVER COMPLIANCE – ALLOWABLE COSTS/COST PRINCIPLES Significant Deficiency Auditee’s Response and Planned Corrective Action FHA is retraining staff on procurement policy and reinforcing the requirement for pre-approval before payment. A checklist will be added to all invoi...

2024-002 – INTERNAL CONTROLS OVER COMPLIANCE – ALLOWABLE COSTS/COST PRINCIPLES Significant Deficiency Auditee’s Response and Planned Corrective Action FHA is retraining staff on procurement policy and reinforcing the requirement for pre-approval before payment. A checklist will be added to all invoices to confirm documentation is in place before submission for payment and a second signer will be responsible for signing invoices in the event of the absence of the Executive Director. Random monthly internal audits will be conducted to ensure continued compliance. Planned Implementation Date of Corrective Action: Immediate Person Responsible for Corrective Action: Benjamin Anako, Fiscal Officer

View Audit 353264

Finding 554536 (2024-004)

Material Weakness 2024

East Casey County Water District

KY

Internal Control / Segregation of Duties § 200.510

The District has determined that it is more cost effective to continue to engage the auditor to prepare the schedule of expenditure of federal awards.

View Audit 353256

Finding 554530 (2024-005)

Material Weakness 2024

Inner City Health Center

CO

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.1 § 200.303

Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on invoice date to ensure the incurred date is within the proper period of performance. Explanation of disagreement with audit finding: There is no disagreement with the ...

Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on invoice date to ensure the incurred date is within the proper period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review grant requirements and make sure that allowable costs are incurred and allocated to the grant within the grant period.

View Audit 353251 Questioned Costs: $1

Finding 554520 (2024-001)

Significant Deficiency 2024

Lupus Foundation of America, Inc.

DC

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

LUPUS FOUNDATION OF AMERICA, INC. CORRECTIVE ACTION PLAN For the Year Ended September 30, 2024 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Lupus Foundation of America, Inc. (the Foundation) submits the following corrective action plan for the year ended September 30, 2024. Independent Public Ac...

LUPUS FOUNDATION OF AMERICA, INC. CORRECTIVE ACTION PLAN For the Year Ended September 30, 2024 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Lupus Foundation of America, Inc. (the Foundation) submits the following corrective action plan for the year ended September 30, 2024. Independent Public Accounting Firm: CBIZ CPAs P.C. 1899 L Street NW, Suite 850 Washington, DC 20036 Audit Period: The finding from the September 30, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding No. 2024-001: Special Tests and Provisions – Significant Deficiency – Internal Control and Compliance Finding ALN 93.068 – Chronic Diseases: Research, Control, and Prevention, Grant Number 5NU58DP006907-04-00, Grant Period: September 30, 2020 to September 29, 2025 Condition The Foundation did not have adequate internal control procedures in place to ensure that certain disclaimers required by the grant agreements are included in written conference materials or publications. Context One of two conference materials we reviewed did not include the required disclaimer. Recommendation It was recommended that management enhance current internal control procedures to ensure that the Foundation is in compliance with the grant’s special provisions that requires certain disclaimers in written conference materials or publications. Action Taken PULSE Team Check-Ins: • Incorporate disclaimer compliance as a standing agenda item during bi-weekly PULSE team meetings to review upcoming materials and confirm adherence to requirements. • The Directors (Content and Federal Grants and Public Health Programs) Program Manager will be assigned to monitor and track the inclusion of disclaimers. Quarterly Compliance Review: • Implement a quarterly review process to assess all conference materials and publications for the inclusion of required disclaimers. • Document review findings and corrective actions, if applicable, to ensure consistent compliance. Executive Leadership Reporting: • Provide updates to executive leadership on all conference materials and publications produced and disclaimer compliance status, including any identified issues and corrective actions taken. • Share compliance trends and recommendations for ongoing improvement to reinforce accountability and oversight. Contact Person Responsible for Corrective Action: Dr. Melicent R. Miller, Director, Federal Grants and Public Health Programs If the US Department of Health and Human Services has questions regarding this plan, please call Cynthia R. Meekins, Chief Financial Officer at 202.349.1141 or meekins@lupus.org Sincerely, Cynthia R. Meekins, MBA Chief Financial Officer Lupus Foundation of America

View Audit 353210

Finding 554518 (2024-002)

Material Weakness 2024

Bassett Creek Senior Housing 092-Ee037

MN

Eligibility HUD Housing Programs Material Weakness

Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant fil...

Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant files in accordance with HUD and will have routine internal audits of tenant files to ensure compliance with HUD regulations. For properties not transitioning to new property management, management believes the reduced volume of properties at one property manager will reduce staff turnover and more efficiently provide the proper training to existing staff to improve compliance with tenant files. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO

View Audit 353189

Finding 554501 (2024-003)

Material Weakness 2024

Rocky Boy Public Schools

MT

Subrecipient Monitoring Cash Management Reporting

FINDING 2024-003: Head Start Program Control Weakness of Filing the Required Semi-Annual and Annual Reports ...

FINDING 2024-003: Head Start Program Control Weakness of Filing the Required Semi-Annual and Annual Reports Response: The District Clerk will contact the Head Start Grant Specialist to ensure the SF424 semi and annual reports are reviewed and approved when submitted. The District should implement a policies and procedures requiring that all Head Start reports be submitted within 30 days of the reporting period end date.

View Audit 353162

Finding 554500 (2024-001)

Significant Deficiency 2024

City of Simi Valley

CA

Reporting Internal Control / Segregation of Duties § 200.328 § 200.502 § 200.510

The City internally identify improvement opportunities in managing grants. As a part of the City’s grant oversight improvement efforts, the City began implementing various processes and internal controls surrounding grant monitoring, which improves the SEFA drafting process and mitigates risks of f...

The City internally identify improvement opportunities in managing grants. As a part of the City’s grant oversight improvement efforts, the City began implementing various processes and internal controls surrounding grant monitoring, which improves the SEFA drafting process and mitigates risks of future inaccuracies. These efforts began in early 2024 and include the following: • Creation of a grant policy that provides City staff with guidance, information, and expectations surrounding grants. • Creation of a master grants database that lists the general ledger fund, applicable project ledger references, status, grant type, start/end dates, granting agency, pass-through agency, grant name, assistance listing numbers, grant amounts, and the grant manager for each grant. This database is now used to verify the completeness and accuracy of the SEFA (beginning FY24). • Formal quarterly monitoring. Each quarter, the City will formally review the grants database with department contacts and grant managers to verify the completeness and accuracy of the database. The City is formalizing this process and plans to include department signoffs evidencing the review process. If any items are missing, the missing component will be identified and added to the database on a timely basis. The City will also utilize this quarterly process to review the grants policy to ensure grant managers are aware of the requirements related to their grants. • The City is in the process of formalizing the SEFA drafting process utilized during the FY24 SEFA preparation, which includes additional mitigating procedures such as reviewing all next FY federal receipts to ensure none of them relate to the SEFA year federal expenditures. Personnel Responsible for Implementation: Marvin Lopez Position of Responsible Personnel: Deputy Administrative Services Director (Fiscal Services) Expected Date of Implementation: June 30, 2025

View Audit 353160

Finding 554475 (2024-002)

Significant Deficiency 2024

Tri-County Community Action Partnership, Inc.

MN

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Head Start - AL #93.6000 Recommendation: The Organization should establish a backup signatory process to ensure that there is always an available individual to provide necessary signatures, even during periods of unavailability. Explanation of disagreement with audit finding: There is no disagreemen...

Head Start - AL #93.6000 Recommendation: The Organization should establish a backup signatory process to ensure that there is always an available individual to provide necessary signatures, even during periods of unavailability. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the findings: We implement a policy to ensure there is someone available to provide signatures. Name(s) of the contact person(s) responsible for corrective action: Penny Paul Planned completion date for corrective action plan: September 30, 2025

View Audit 353111

Finding 554458 (2024-002)

Material Weakness 2024

Northeast Metropolitan Intermediate School District No. 916

MN

Internal Control / Segregation of Duties Special Tests & Provisions Material Weakness

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 – EDUATION STABILIZATION FUND – FEDERAL ALN 84.425 2024-002 Internal Control Over Compliance and Material Noncompliance With S...

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 – EDUATION STABILIZATION FUND – FEDERAL ALN 84.425 2024-002 Internal Control Over Compliance and Material Noncompliance With Special Tests and Provisions Over Wage Rate Requirements Finding Summary 29 CFR part 5 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including wage rate requirements applicable to the education stabilization fund. During our audit, we noted the District did not have sufficient controls in place resulting in material noncompliance within its education stabilization funds federal program to ensure compliance with wage rate requirements related to minor remodeling, renovation, or construction contracts that are over $2,000 that use laborers and mechanics that are required to meet Davis-Bacon Act prevailing wage rate requirements. Corrective Action Plan Actions Planned – The District is in the process of reviewing and updating its policies and procedures relating to wage rate requirements for its federal programs to ensure compliance with the Uniform Guidance in the future. The review of procedures will also include steps to ensure that district personnel are following the requirements of the Uniform Guidance related to wage rate requiremetns and maintaining appropriate documentation. Official Responsible – The District’s Director of Finance and Operations, Mark Kumlien. Planned Completion Date – June 30, 2025. Disagreement With or Explanation of Finding – The District is in agreement with this finding. Plan to Monitor – The District’s Director of Finance and Operations, Mark Kumlien, will assure appropriate internal controls and procedures are updated and in place to ensure compliance with wage rate requirements.

View Audit 353092

Corrective Action Plans

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