Corrective Action Plans

Finding 388536 (2023-002)

Significant Deficiency 2023

State System of Higher Education, Commonwealth of Pennsylvania

PA

Student Financial Aid Reporting Significant Deficiency § 200.303

West Chester University: We have recently modified our submission schedule to ensure we have adequate time to prepare our files, conduct our pre-submission checks, and resolve errors prior to the monthly exchange of data between the National Student Clearinghouse and NSLDS. We will continue to monit...

West Chester University: We have recently modified our submission schedule to ensure we have adequate time to prepare our files, conduct our pre-submission checks, and resolve errors prior to the monthly exchange of data between the National Student Clearinghouse and NSLDS. We will continue to monitor the time it takes to complete these tasks and make any necessary modifications to support timely reporting to NSLDS. East Stroudsburg University: The University Records’ Office will implement policy and procedures to ensure students’ enrollment statuses are being reported to NSLDS through the National Student Clearinghouse. Reporting will occur on a monthly basis by means of the University Records’ Office transmitting a file to the National Student Clearinghouse. The University Records’s Office will monitor student statuses in NSLDS by randomly sampling students reported through the National Student Clearinghouse to ensure the accuracy of data being reported to NSLDS. Kutztown University: We re-evaluated our reporting procedures and worked with the Registrar’s Office to further redefine our process(es). The Registrar’s Office submits monthly transmissions to NSC (National Student Clearinghouse), who in turn updates our information to NSLDS. A new resource was identified for this responsibility, who is continuously monitoring our submissions to ensure they are accepted in a timely manner. A financial aid resource works in conjunction with the Registrar’s Office to ensure errors are addressed timely to certify the accuracy of our reporting. Cheyney University: Cheyney University of Pennsylvania currently utilizes the National Student Clearinghouse as a third-party service provider for enrollment reporting and provides all enrollment data to NSC, believing that enrollment would be reported to NSLDS in compliance with federal regulations; unfortunately, NSC only includes enrollment data for students on the enrollment roster they receive from the National Student Loan Data System (NSLDS). Cheyney University is a Heightened Cash Monitoring 2 (HCM2) institution, and students' Title IV aid/disbursements are reported differently than advance pay institutions. Students did not appear on the rosters, so NSC did not provide the enrollment data to NSLDS. While investigating the issues with enrollment reporting for our HCM2 students, Cheyney University learned that NSLDS did not receive students' enrollment from NSC. As of Spring 2023, Cheyney University has implemented procedures to report enrollment for all Title IV recipients to NSLDS. Beginning August 2024, Cheyney University will begin utilizing BANNER to create the required enrollment file and transmit the information directly to NSLDS vis EdConnect or TDClient.

View Audit 300242

Finding 388531 (2023-001)

Significant Deficiency 2023

Cornerstone Montgomery, Inc.

MD

Allowable Costs / Cost Principles Reporting Significant Deficiency

COVID 19 - Demonstration Programs to Improve Community Mental Health Services 93.829 Recommendation: We recommend internal controls over reporting be enhanced to ensure evidence is maintained to support the reports and review performed over the reports. Explanation of disagreement with audit findi...

COVID 19 - Demonstration Programs to Improve Community Mental Health Services 93.829 Recommendation: We recommend internal controls over reporting be enhanced to ensure evidence is maintained to support the reports and review performed over the reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are in the process of re-evaluating the reporting process to ensure documentation is maintained to support the reporting requirements. Name of the contact person responsible for corrective action: Lisa Katz, Chief Program Officer Planned completion date for corrective action plan: Currently underway and planned to be completed by June 30, 2024.

View Audit 300238

Finding 388530 (2023-005)

Material Weakness 2023

City of Jackson, Tennessee

TN

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties

We will ensure future reports include all previously omitted expenditures and work to implement controls sufficient to reconcile the programatic reporting to the general ledger on a quarterly basis.

View Audit 300234

Finding 388529 (2023-001)

Material Weakness 2023

Consolidated North County Levee District

MO

Material Weakness Reporting Internal Control / Segregation of Duties

2023-001 Material Weakness in Internal Control over financial reporting Criteria: Management is responsible for establishing and maintaining internal controls in the financial reporting system and for the fair presentation of the financial position, results of operations, and disclosures in th...

2023-001 Material Weakness in Internal Control over financial reporting Criteria: Management is responsible for establishing and maintaining internal controls in the financial reporting system and for the fair presentation of the financial position, results of operations, and disclosures in the financial statements, in conformity with the cash basis of accounting. Condition: The District does not have an individual that has the ability to evaluate the completeness and accuracy of the statements presented in accordance with the cash basis of accounting. Cause: The District only has a volunteer board and has elected to outsource the preparation of the annual financial statements. Effect: The District must rely on its external auditors to determine adherence to applicable cash basis of accounting. CORRECTIVE ACTION PLAN RESPONSE: Management concurs with this finding and will continue to evaluate the risk of outsourcing financial statement preparation versus the cost of staffing at this level. Anticipated completion date: 6/30/24 Responsible party: Kevin Machens, President Please contact Kevin Machens at 314-750-2519 with questions regarding this plan.

View Audit 300231

Finding 388522 (2023-003)

Material Weakness 2023

Eagle Grove Community School District

IA

Internal Control / Segregation of Duties

SEE REPSONSE AND CORRECTIVE ACTION PLAN AT 2023-001

View Audit 300225

Finding 388519 (2023-003)

Significant Deficiency 2023

City of Richmond

VA

Questioned Costs Subrecipient Monitoring Period of Performance § 200.303 § 200.308 § 200.309 § 200.403

Recommendation: We recommend that the Department review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. A...

Recommendation: We recommend that the Department review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A correction will be made to reduce the request by the overstated (by 1 day) amount in the 3/31 payroll report. A credit was issued to FEMA for the amount of $19,871.26 on Monday March 13, 2023 in relation to the finding noted. Name(s) of the contact person(s) responsible for corrective action: Angelia Adediran, Deputy Director City of Richmond Fire and Emergency Services

View Audit 300220 Questioned Costs: $1

Finding 388512 (2023-003)

Significant Deficiency 2023

Dupage Housing Authority

IL

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Finding 2023-003: Overpayments to Landlords (Significant Deficiency) Corrective Action Plan: DHA Management has worked with our financial institution to ensure that the positive pay function is working and duplicate payments will not be posted to Landlord accounts. Name of Responsible Person: Cheron...

Finding 2023-003: Overpayments to Landlords (Significant Deficiency) Corrective Action Plan: DHA Management has worked with our financial institution to ensure that the positive pay function is working and duplicate payments will not be posted to Landlord accounts. Name of Responsible Person: Cheron Corbett Completion Date: July 31, 2023

View Audit 300217

Finding 388511 (2023-002)

Significant Deficiency 2023

Dupage Housing Authority

IL

HUD Housing Programs Internal Control / Segregation of Duties Reporting

Finding 2023-002: Late Submission of Unaudited Data to REAC (Significant Deficiency) Corrective Action Plan: Due to the abrupt quitting of our previous Comptroller cause a delay in the submission of our unaudited financials. DHA has hired a new Comptroller and we have monthly meetings to ensure that...

Finding 2023-002: Late Submission of Unaudited Data to REAC (Significant Deficiency) Corrective Action Plan: Due to the abrupt quitting of our previous Comptroller cause a delay in the submission of our unaudited financials. DHA has hired a new Comptroller and we have monthly meetings to ensure that all accounting data is being recorded timely. This will allow us to submit timely financials to HUD. . Name of Responsible Person: Cheron Corbett, Executive Director Projected Completion Date: December 31, 2024

View Audit 300217

Finding 388478 (2023-002)

Significant Deficiency 2023

Town of Middlebury, Vermont

VT

Internal Control / Segregation of Duties Reporting Special Tests & Provisions

Recommendation: To correct these deficiencies, management would need to hire personnel with adequate accounting experience to perform these functions. The Town would need to weigh the costs of these corrections verse the benefit.

View Audit 300206

Finding 388475 (2023-001)

None 2023

Universidad Central Del Caribe, Inc.

PR

Student Financial Aid Eligibility Reporting

To correct the student reporting process in NSLDS and in addition to the actions already implemented, the following actions will be executed: 1. By June 30, 2024, achieve 100 % accurate reporting by performing a bi-monthly internal reconciliation (July, September, November, January, March, May): a. ...

To correct the student reporting process in NSLDS and in addition to the actions already implemented, the following actions will be executed: 1. By June 30, 2024, achieve 100 % accurate reporting by performing a bi-monthly internal reconciliation (July, September, November, January, March, May): a. Bi-monthly the first day of the month of the reporting period, the IEO and Registrar offices will prepare the Enrollment Changes List (ECL). The list will include withdrawals, LOA, graduations, and other enrollment status changes. The ECL will be conciliated with each academic program leader within 24 hours. b. 2 calendar days after (a), the Registrar will certify and sign the list to assure the enrollment status is accurate. c. 3 calendar days after (b), the Registrar Office and IEO will do the data entry in the NSLDS platform. d. 1 calendar days after (c), the reconciled Enrollment Changes List will be revised by the Assistant Dean of Licensing and Accreditation for validation. e. 2 days calendar after (d), the reconciled and validated ECL be revised by Academic Dean and Vice-President for certification of the accurate NSLDS reporting. 2. By June 30, 2024, achieve 100 % of accurate reporting to the NSLDS by continuing the implementation of the monthly process of reconciliation of withdrawals and verification of attendance in the SharePoint. 3. By June 30, 2024, assure quality improvement through re-training of all Registrar Office staff and academic programs leadership in the processes and responsibilities regarding compliance reporting of student status in NSLDS and our internal policies and procedures.

View Audit 300200

Finding 388472 (2023-005)

None 2023

Saint Elizabeth University

NJ

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

Federal Direct Loans Reconciliations Planned Corrective Action: The University’s Financial Aid Office will review the reconciliations to ensure that the Direct Loan Program is reconciled. We will also refer the ED announcement DL-22-07 to maintain consistent and accurate reconciliations. Person ...

Federal Direct Loans Reconciliations Planned Corrective Action: The University’s Financial Aid Office will review the reconciliations to ensure that the Direct Loan Program is reconciled. We will also refer the ED announcement DL-22-07 to maintain consistent and accurate reconciliations. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024

View Audit 300191

Finding 388469 (2023-004)

Significant Deficiency 2023

Saint Elizabeth University

NJ

Questioned Costs Student Financial Aid Significant Deficiency

Unofficial Withdrawals Planned Corrective Action: The University will run zero credit reports at the end of each semester to ensure all potential unofficial withdrawals are followed up on so that R2T4’s are completed timely when required. Person Responsible for Corrective Action Plan: Nicholas Cap...

Unofficial Withdrawals Planned Corrective Action: The University will run zero credit reports at the end of each semester to ensure all potential unofficial withdrawals are followed up on so that R2T4’s are completed timely when required. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: June 30th, 2024

View Audit 300191 Questioned Costs: $1

Finding 388452 (2023-002)

Significant Deficiency 2023

Colorado Mountain College

CO

Questioned Costs Student Financial Aid Subrecipient Monitoring § 200.303

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Reco...

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: CLA recommends that the College review the requirement and implement a monitoring control to monitor the checks throughout the year. In addition, for the checks outstanding greater than 240 days, the College should return the funding to the U.S. Department of Education. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To enhance the 240 Day Outstanding refund check processing efficiency and compliance, a streamlined procedure was developed and implemented to monitor all uncashed refund checks, including those from federal aid sources. This process will involve utilizing an Informer report every two weeks to compile a comprehensive list of uncashed refund checks for current and prior terms. Upon identification, a system-generated communication will be promptly dispatched to students, notifying them of the outstanding refund check and providing clear instructions to contact the Business Office. Calculations will be performed to ascertain if the refund originates from a federal aid source. For students with federal aid-related outstanding refunds, outreach efforts will be undertaken. Additionally, a progressive maintained cumulative report will serve as a real-time monitoring mechanism to track the status of refunds and ensure timely compliance. Continuous open communication will be maintained with the Financial Aid and Compliance team, facilitating the provision of student refunds requiring action and fostering collaboration across departments to address any outstanding issues effectively. The above-detailed process has already proven effective and noticeably successful in addressing the challenges associated with uncashed refund checks, particularly those originating from federal aid sources. Moving forward, this process will be continuously optimized and refined as system enhancements allow. Regular evaluations will be conducted to identify areas for improvement and implement necessary adjustments, ensuring that the refund processing workflow remains efficient, compliant, and responsive to the evolving needs of both students and regulatory requirements. This commitment to ongoing optimization underscores our dedication to providing timely and accurate refunds while upholding the highest standards of financial stewardship and accountability. Name(s) of the contact person(s) responsible for corrective action: Renee McBride Planned completion date for corrective action plan: January 2024

View Audit 300168 Questioned Costs: $1

Finding 388425 (2023-001)

Material Weakness 2023

Christus Health

TX

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

Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...

Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2023 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.

View Audit 300159 Questioned Costs: $1

Finding 388424 (2023-002)

Significant Deficiency 2023

Catholic Community Services of Southern Arizona, Inc.

AZ

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking

Secondary Review of Billings (Significant Deficiency) Federal Agency: U.S. Department of Health and Human Services Program Title: Child Care and Development Block Grant Assistance Listing Number: 93.575 Federal Award Source: Pass-Through Funding Pass-Through Entity: Arizona Department of Economic S...

Secondary Review of Billings (Significant Deficiency) Federal Agency: U.S. Department of Health and Human Services Program Title: Child Care and Development Block Grant Assistance Listing Number: 93.575 Federal Award Source: Pass-Through Funding Pass-Through Entity: Arizona Department of Economic Security Pass-Through Identifying Number: SX222367 Criteria – Section §200.303 of the Uniform Guidance states that a non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition and Context – During our audit of allowable activities, we noted the Organization did not conduct a secondary internal supervisory review of the monthly billings for this program prior to submission to the funding source. Cause and Effect – Due to a shortage in staff, all 12 monthly billings for this program were prepared by one individual and were not reviewed and approved by secondary supervisory personnel. Questioned Costs – None identified. Recommendation – We recommend that the Organization improve its internal controls over the preparation of billings for this program to ensure all billings are reviewed and approved by secondary supervisory personnel. View of Responsible Officials: We agree with the finding. We have implemented procedures to ensure secondary reviews of all billings. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: CCS will improve its internal controls over the preparation of all billings. Effective April 1, 2024, Tammy Gallegos, CCS Accounting Manager, will make certain all billings are reviewed and approved by a secondary supervisor. The Accounting Manager will check off and sign off on a listing of all billings in an effort to ensure and document that 1) the billings were reviewed by a secondary supervisor, 2) the billings were submitted to the payers, and 3) the billings were submitted on a timely manner.

View Audit 300150

Finding 388423 (2023-001)

Significant Deficiency 2023

Catholic Community Services of Southern Arizona, Inc.

AZ

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring

Procurement (Significant Deficiency) and Compliance Federal Agency: U.S. Department of Homeland Security Program Title: Emergency Food & Shelter National Board Program (“EFSP”) Assistance Listing Number: 97.024 Federal Award Source: Pass-Through Funding Pass-Through Entity: Pima County Pass-Through...

Procurement (Significant Deficiency) and Compliance Federal Agency: U.S. Department of Homeland Security Program Title: Emergency Food & Shelter National Board Program (“EFSP”) Assistance Listing Number: 97.024 Federal Award Source: Pass-Through Funding Pass-Through Entity: Pima County Pass-Through Identifying Number: CT-GMI-21-452 Criteria – Section §200.320 of the Uniform Guidance requires that when the value of the procurement for property or services under a Federal financial assistance award exceeds the Simplified Acquisition Threshold, a formal procurement method is required, such as a sealed bid or proposal. In addition, these formal procurement methods require public advertising. Condition – During our audit of the procurement requirements for the EFSP program, we noted the Organization utilized a vendor who in total was paid more than the Simplified Acquisition Threshold; however, the Organization did not utilize a formal procurement method in selecting this vendor as required by their policies and the Uniform Guidance. Cause – The finding appears to be the result of an immediate need to obtain services and an oversight to subsequently conduct a formal procurement method. Effect and Context – By not adhering to a formal procurement method, the Organization may or may not have chosen the best vendor to provide the services. There was only one vendor whose payments exceeded the Simplified Acquisition Threshold during the audit period. Our sample was a statistically valid sample. Questioned Costs – None identified. Recommendation – We recommend the Organization provide periodic training to its program staff regarding procurement requirements per the Uniform Guidance and consider modifying its procurement related internal controls to ensure all staff follow the Organization’s procurement policies. View of Responsible Officials: We are in agreement with the finding and are in the process of updating our procedures to mitigate issues in the future. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: CCS has updated its purchasing policy as of March 22, 2024. The purchasing policy will be included as part of the program staff’s required 2024 annual training effective April 1, 2024. The Relias Learning platform will be the mechanism used for this training. Staff will be given a deadline of April 30, 2024 to complete this training. In addition, Tammy Gallegos, the CCS Accounting Manager will monitor large purchases by vendor on a monthly basis. This is to ensure that vendors providing goods or services to CCS that meet or exceed the Single Acquisition Threshold per federal regulations follow a formal procurement method, such as soliciting bids. Bids will be kept with the vendors’ file in the CCS Business Office.

View Audit 300150

Finding 388413 (2023-103)

Material Weakness 2023

Santa Cruz County

AZ

Reporting Internal Control / Segregation of Duties § 200.303

Assistance Listings number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Contact Person(s): Mauricio A. Chavez, Deputy County Manager/CFO Anticipated completion date: April 30, 2024 The County’s finance department reported the entirety of the allo...

Assistance Listings number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Contact Person(s): Mauricio A. Chavez, Deputy County Manager/CFO Anticipated completion date: April 30, 2024 The County’s finance department reported the entirety of the allocation based on County’s interpretation of the final rule and multiple subsequent reporting guidelines. The County will revise and resubmit reports to the Treasury Department and will work with staff to correct any deficiencies for future reports. The County will meet with staff to assess all present and future grant reporting guidelines.

View Audit 300146

Finding 388408 (2023-004)

Material Weakness 2023

City of Atlanta

GA

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

Name of Contact Person Responsible for Corrective Action Plan: Jerry Deloach, Chief Risk Officer - Enterprise Risk Management Corrective Action Plan: The City of Atlanta’s Department of Enterprise Risk Management (ERM) is now calendaring the quarterly reports due dates and immediately following the ...

Name of Contact Person Responsible for Corrective Action Plan: Jerry Deloach, Chief Risk Officer - Enterprise Risk Management Corrective Action Plan: The City of Atlanta’s Department of Enterprise Risk Management (ERM) is now calendaring the quarterly reports due dates and immediately following the timely filing before transmitting a copy of the report to the City of Atlanta’s Grants Accounting area. Anticipated Completion Date: Fiscal year 2024

View Audit 300142

Finding 388349 (2023-007)

Material Weakness 2023

Department of Education, State of Hawaii

HI

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

2023-007 Special Tests and Provisions – Material Weakness View of Responsible Officials Management agrees with the findings and recommendations. Corrective Action Plan The audit finding was due in large part to a vacancy in the Department ESSER grant support position that arose in the first qua...

2023-007 Special Tests and Provisions – Material Weakness View of Responsible Officials Management agrees with the findings and recommendations. Corrective Action Plan The audit finding was due in large part to a vacancy in the Department ESSER grant support position that arose in the first quarter of the fiscal year, which contributed to the breakdown in construction project tracking. The Department hired a replacement for this grant support position in the second quarter of the fiscal year, and during the third quarter hired a second grant support position to ensure enhanced support capacity and continuity. These two individuals continue to comprise the ESSER Grant Management Office (team) and in the fourth quarter of the fiscal year initiated a process to document school and complex area use of ESSER funds for construction purposes. The team held a department-wide informational webinar in partnership with the Department’s Office of Facilities and Operations on May 22, 2023. The webinar agenda included the newly implemented pre-approval construction application process and federal requirements pursuant to Title 2, Section 200, Appendix II, of the Code of Federal Regulations (CFR). The team will continue to work with the Department’s Complex Area Staff to reiterate the award requirements and examine construction-related contracts over $2,000 to verify compliance with the award requirements. Contact Person: Brian Hallett Assistant Superintendent and CFO Office of Fiscal Services Anticipated Completion Date: June 30, 2024

View Audit 300126

Finding 388348 (2023-006)

None 2023

Department of Education, State of Hawaii

HI

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

2023-006 Matching, Level of Effort and Earmarking – Control Deficiency View of Responsible Officials The Department generally agrees with the findings and recommendations. However, it should be noted that the earmarking findings described here are issues that were identified by the Department in ...

2023-006 Matching, Level of Effort and Earmarking – Control Deficiency View of Responsible Officials The Department generally agrees with the findings and recommendations. However, it should be noted that the earmarking findings described here are issues that were identified by the Department in June 2023 (prior to being audited) and a corrective action plan was put into place at that time. It had not yet been completed at the time of the audit and so was not reflected in the grant years that were used for this audit. Corrective Action Plan Note: As stated above, the earmarking issues raised by the audit were issues that had come to our attention in June of 2023. A corrective plan was established at that time. The steps for correcting these issues were begun June 21, 2023 but had not yet been completed at the time of the audit. The Corrective Action Plan being presented here is a modified version of this plan that encompasses the original plan as well as documents steps to address related issues raised in this audit. [TABLE] Contact Person: Kathleen Grondin, Title III Specialist English Learners Office Office of Student Support Services Anticipated Completion Date: July 30, 2024

View Audit 300126

Finding 388347 (2023-005)

None 2023

Department of Education, State of Hawaii

HI

Special Tests & Provisions Internal Control / Segregation of Duties

2023-005 Special Tests and Provisions – Control Deficiency View of Responsible Officials Management agrees with the finding and recommendation. The Department is currently in the process of hiring personnel to assist with providing services. Corrective Action Plan Migrant Education Program lea...

2023-005 Special Tests and Provisions – Control Deficiency View of Responsible Officials Management agrees with the finding and recommendation. The Department is currently in the process of hiring personnel to assist with providing services. Corrective Action Plan Migrant Education Program leadership will review the criteria identified in the Title I, Part C, Section 1304 of the Every Student Succeeds Act, which requires the Department to give priority services to officially identified Priority for Service designated students. Program leadership will ensure that personnel are familiar with all grant requirements and retain necessary documentation to comply with federal program requirements. A statewide memo will be distributed to include: • A summary about the identification process for determining who are Migrant Education students and the state program database that tracks this information. • Review of all Federal and State education obligations to service Migrant Education students. • Include a list of potential support services and resources to service Migrant Education students. • Information will be added to the Leadership Bulletin to help inform and remind leaders about the state’s obligations to support Migrant Education students. • Additional dissemination of this information will be shared by Assistant Superintendent Kalama to all Complex Area Superintendents. Contact Person: Bruce Kawachika, State Migrant Education Program Manager Student Services Branch English Learner/Migrant Education Section Office of Student Support Services Anticipated Completion Date: December 31, 2024

View Audit 300126

Finding 388346 (2023-004)

None 2023

Department of Education, State of Hawaii

HI

Internal Control / Segregation of Duties Eligibility § 200.403

2023-004 Student Eligibility – Control Deficiency View of Responsible Officials Management agrees with the finding and provides more context regarding the finding. Participant eligibility procedures are based on USC §3272 and §3102 were created for Adult Education Family Literacy Act (AEFLA)-fun...

2023-004 Student Eligibility – Control Deficiency View of Responsible Officials Management agrees with the finding and provides more context regarding the finding. Participant eligibility procedures are based on USC §3272 and §3102 were created for Adult Education Family Literacy Act (AEFLA)-funded adult schools. The procedures were distributed, and training was provided on March 31, 2023 to address prior audit Finding No. 2022-03. The enrollment record that did not meet the criteria for eligibility in the Single Audit Fiscal Year Ending 06/30/23 had an intake date of September 15, 2022, approximately six months before the procedures were distributed and training provided. A corrective action has already taken place through the March 31, 2023 procedures distribution and training. The AEFLA-funded adult schools are aware that all participants reported in the AEFLA reporting system, known as the National Reporting System, including participants in workplace adult education and literacy activities as defined in United States Code, Title 29, Chapter 32 Workforce Innovation and Opportunity Act §3272, must meet AEFLA eligibility requirements. Corrective Action Plan Participant eligibility procedures for AEFLA-funded adult schools based on USC §3272 and §3102 will be reviewed annually with AEFLA-funded adult schools through a technical assistance session. The procedures inform the staff of the AEFLA-funded adult school of the following: • The Workforce Innovation and Opportunity Act • The Adult Education and Family Literacy Act • The relevant US Code and Code of Federal Regulations • A definition of AEFLA-eligible individuals • Categories of funding and their purpose • The role of the US DOE Office of Career Technical and Adult Education • The role of the Hawaii state director for adult education • The role of the AEFLA-funded local service providers Contact Person: Dan Miyamoto, TA Community Education Specialist Curriculum Innovation Branch Office of Curriculum and Instructional Design Anticipated Completion Date: August 31, 2024

View Audit 300126

Finding 388344 (2023-003)

None 2023

Department of Education, State of Hawaii

HI

Cash Management Period of Performance Reporting § 200.344

2023-003 Cash Management / Period of Performance – Control Deficiency View of Responsible Officials Management appreciates the opportunity to respond to the findings of the audit. The Hawaii State Public Library System (HSPLS) makes every attempt to meet all federal laws and guidelines for fundin...

2023-003 Cash Management / Period of Performance – Control Deficiency View of Responsible Officials Management appreciates the opportunity to respond to the findings of the audit. The Hawaii State Public Library System (HSPLS) makes every attempt to meet all federal laws and guidelines for funding that is received. Many factors outside our control directly impacted the timely payment of vendors as noted in the audit. Specifically: 1) Federal budget uncertainty; delay in receiving federal funding. For the past several years, Congress has not been able to pass a comprehensive federal budget, and instead has funded the Grants to States fund via continuing resolutions making it difficult to plan out expenditures with any certainty. In addition to lacking the certainty of when and/or if funding will be available, the Grants to States funds have not been released to states in a timely manner, including during the audit period. Instead of at the beginning of the federal fiscal year around October 1st, funding has been received months later, leaving States with a lot less time to procure, process and receive purchases. This means we do not have access to the funding for the full grant cycle and directly impacts if/when we are able to procure goods and services. 2) Supply chain and shipping issues. The State of Hawaii procurement requirements do not allow us to pay for goods and services until we receive the products or the services are rendered satisfactorily. HSPLS continues to face significant supply chain and shipping issues which affects the timely payment of vendors. As an island state in the middle of the Pacific Ocean, there are often delays in receiving an entire shipment on time in full, even post-pandemic. For large products or orders, sometimes the order and/or related parts are not shipped together further delaying completion of the order by the vendor and issuance of the invoice. In many instances, vendors do not send their invoices in a timely manner, preventing HSPLS from dispersing funds in a timely manner. 3) Federal agency guidance. We would also like to note that in the past, we have contacted our funding federal agency and let them know that we have had challenges with supply chain and shipping issues. We were advised that it was understood, and that as long as we had encumbered the funds by September 30, that we would be able to use the funding that was allotted to us even if the invoice is received after the close of the federal fiscal year. Corrective Action Plan We will do our best to continue to monitor and minimize any untimely disbursements of federal funds. Contact Person: Stacy A. Aldrich State Librarian Hawaii State Public Library System Anticipated Completion Date: Ongoing

View Audit 300126

Finding 388343 (2023-002)

Material Weakness 2023

Department of Education, State of Hawaii

HI

Subrecipient Monitoring Material Weakness Reporting

2023-002 Reporting – Material Weakness View of Responsible Officials Administration agrees with the findings and recommendations. Corrective Action Plan The Office of Monitoring and Compliance (MAC) will provide training to recipients when funds are allocated within the Department. The Policy, ...

2023-002 Reporting – Material Weakness View of Responsible Officials Administration agrees with the findings and recommendations. Corrective Action Plan The Office of Monitoring and Compliance (MAC) will provide training to recipients when funds are allocated within the Department. The Policy, Innovation, Planning and Evaluation Branch (PIPE) will communicate with the Office of Fiscal Services and MAC on a semi-annual basis to start the reporting process on December 1 and June 1 of each year to meet the January 31 and July 31 respective deadlines. Additionally, PIPE has identified a dedicated staff member who will spearhead the administration of this grant to ensure that any changes in the reporting requirements as defined in the OIA Cooperative Agreement will be quickly identified and followed. Contact Persons: Ken Kakesako, Director Policy, Innovation, Planning and Evaluation Branch Office of Strategy Innovation and Performance Jacy Yamamoto, Interim Director Office of Monitoring and Compliance Office of the Deputy Superintendent Anticipated Completion Date: June 1, 2024

View Audit 300126

Finding 388328 (2023-002)

Significant Deficiency 2023

Memorial Hospital of Laramie County D/b/a Cheyenne Regional Medical Ce

WY

Allowable Costs / Cost Principles Eligibility Period of Performance § 200.303

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: The Medical Center was not able to provide supporting invoices for t...

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: The Medical Center was not able to provide supporting invoices for two of the testing selections. An additional selection contained a keying error. Responsible Individuals: Amy Spieker, Director Community Health and Analysis, and Erika Novick, Operations Manager Corrective Action Plan: The Program Director and Operations Manager will ensure all invoices are properly submitted and approved prior to including the expenses in the reimbursement requests. Program Director/Director of Community Health and Analysis will review draws/invoices to ensure amounts on supporting documents agree to the amounts submitted in the reimbursement requests. Finance will also revise Corporate Card Policy by June 30, 2024, to include expense reports being submitted in a timely manner. Finance will review open expense reports with card holder and their supervisor monthly. Anticipated Completion Date: April 1, 2024

View Audit 300118

Corrective Action Plans

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