Corrective Action Plans

Finding 382387 (2023-001)

Significant Deficiency 2023

WA

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

In response to audit finding 2023-001, Dave Purchase Project will immediately implement the following corrective actions: • DPP will review all current employee files by 03.08.2023 to ensure that a background check has been completed and evidence of the check is present in each employee file; • All ...

In response to audit finding 2023-001, Dave Purchase Project will immediately implement the following corrective actions: • DPP will review all current employee files by 03.08.2023 to ensure that a background check has been completed and evidence of the check is present in each employee file; • All current staff will have a new background check run and placed in their file: • All new hires/volunteers/interns will have a background check conducted on their first day of employment/volunteering/internship, while they fill out their new hire/volunteer/internship paperwork;No new staff/volunteers/interns will be deployed to their work site until the check has been completed, and; • any background check findings are satisfactorily addressed; • their paperwork is appropriately filed; No new staff/volunteers/interns will be deployed if background check findings conflict with federal requirements regarding employment i.e ., OIG is required by law to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs; patient abuse or neglect; felony convictions for other health care - related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription , or dispensing of controlled substances; • Every January all current DPP staff will have an updated background check completed and evidence of such placed in their employee file

View Audit 296113

Finding 382384 (2023-001)

Significant Deficiency 2023

Markesan District Schools

WI

Internal Control / Segregation of Duties

Finding #2023-001 - Segregation of Duties (Prior Year Finding #2022-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Criteria: Checks and balances should be in place to allow management or employees, in the normal course of performing...

Finding #2023-001 - Segregation of Duties (Prior Year Finding #2022-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Criteria: Checks and balances should be in place to allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct any misstatements on a timely basis. Cause: A small number of individuals within the District's administration perform substantially all accounting functions and have control over both records and assets. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected on a timely basis. Recommendation: Procedures should be implemented segregating duties among different employees. Management should continue to maintain a working knowledge of matters relating to the district's operations. Response: We agree and will continue to provide supervision and monitor accounting information and operations, obtain explanations for variances from unexpected results and work to increase segregation of duties. The Assistant to the Business Manager will continue to clear checks in Skyward as part of the bank reconciliation process. The District Administrator will review and initial all journal entries. The Assistant to the Business Manager will review payroll on a monthly basis, and the District Administrator will review payroll on a quarterly basis.

View Audit 296095

Finding 382379 (2023-002)

None 2023

Miami Dade County District School Board

FL

Questioned Costs Subrecipient Monitoring HUD Housing Programs

The School Board Administration Building (SBAB),Cooling Tower Replacement project 02190000 was originally funded using Comprehensive Needs for the Design Phase. When the project was ready to commence to the construction phase it was decided to fund this phase with ESSER Funds. Subsequently, the c...

The School Board Administration Building (SBAB),Cooling Tower Replacement project 02190000 was originally funded using Comprehensive Needs for the Design Phase. When the project was ready to commence to the construction phase it was decided to fund this phase with ESSER Funds. Subsequently, the contractor was not advised this project was subject to Davis Bacon requirements. All other projects reviewed did adhere to the Davis Bacon prevailing wages and certified payroll. We consider the SBAB Project to be an isolated incident. Moving forward, we have changed our procedures hen requesting project numbers. The requestor must identify the funding source and include a note in the project description when requesting project numbers. We have also updated our Contracting Software so that projects funded with ESSER Funds are identified at the beginning of the project. These procedures will prevent this from occurring in the future.

View Audit 296081 Questioned Costs: $1

Finding 382378 (2023-001)

Significant Deficiency 2023

Miami Dade County District School Board

FL

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

Maintenance will conduct training workshops for all administrators on the topic of the Davis Bacon Act. The specific requirements including applicability of the Act to project type signage, certified payroll, weekly payments, etc. will be part of the training agenda.

View Audit 296081

Finding 382366 (2023-002)

Significant Deficiency 2023

City of Dixon

CA

Subrecipient Monitoring Internal Control / Segregation of Duties

The City has acknowledged that internal controls have not been established to review the work performed by the third-party consultant that has been engaged to oversee the HOME program to ensure federal award requirements are being followed. The City will be hiring an Economic Development Specialist ...

The City has acknowledged that internal controls have not been established to review the work performed by the third-party consultant that has been engaged to oversee the HOME program to ensure federal award requirements are being followed. The City will be hiring an Economic Development Specialist who will oversee this grant program and review the report from the consultant to ensure that all requirements are implemented, completed and submitted to the State.

View Audit 296069

Finding 382357 (2023-008)

Material Weakness 2023

Lake Ridge Schools

IN

Matching / Level of Effort / Earmarking Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

FINDING 2023-008 Information on the federal program: Subject: COVID-19 - Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listings Number: 84.425D Federal A...

FINDING 2023-008 Information on the federal program: Subject: COVID-19 - Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listings Number: 84.425D Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Modified Opinion Contact Persons Responsible for Corrective Action: Regin Johnson, Title I Director Adrian Wilkerson, Chief Financial Officer Contact Phone Number and Email Address: (219) 838-1819 rjohnson@lakeridgeschools.net awilkerson@lakeridgeschools.net Condition: Construction contracts in excess of $2,000 financed by federal assistance funds must pay wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (DOL) to their laborers and mechanics. Nonfederal entities are to include in their construction contracts subject to the Wage Rate Requirements a provision that the contractor or subcontractor comply with these requirements and the DOL regulations. This would include a requirement to submit a copy of the payroll and statement of compliance to the entity for each week in which contract work was performed. Context: The School Corporation had not designed, nor implemented a system of internal control to ensure that construction contracts in excess of $2,000 paid from federal grant funds included a prevailing wage rate clause. One construction contract, totaling $4,000,000 was paid from the Education Stabilization Fund grant funds during the audit period. The single contract was tested and it did not contain the required prevailing wage rate clause. Additionally, certified payrolls were not obtained until after the School Corporation was issued an ESSER Construction Monitoring Report in late 2023. The School Corporation only obtained "sample" of certified payrolls and did not obtain all of the certified payrolls for the work performed within the grant period. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Chief Financial Officer and Grant Director will ensure that all future construction contracts contain the prevailing wage rate clause required by the program. Additionally, the Chief Financial Officer will review and approve all certified payrolls and compliance statements submitted by contractors and subcontractors in order to ensure compliance with the program. Anticipated Completion Date: Immediate

View Audit 296034

Finding 382355 (2023-007)

Material Weakness 2023

Lake Ridge Schools

IN

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.400 § 200.403

FINDING 2023-007 Information on the federal program: Subject: COVID-19 - Education Stabilization Fund – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listings Number: 84.425...

FINDING 2023-007 Information on the federal program: Subject: COVID-19 - Education Stabilization Fund – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listings Number: 84.425D Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Persons Responsible for Corrective Action: Regin Johnson, Title I Director Chris Akers, Treasurer Adrian Wilkerson, Chief Financial Officer Contact Phone Number and Email Address: (219) 838-1819 rjohnson@lakeridgeschools.net cakers@lakeridgeschools.net awilkerson@lakeridgeschools.net Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Activities Allowed or Unallowed and Allowable Costs/Cost Principles compliance requirements. Context: A number of transfer adjustments were made during the audit period from Corporation fund 7923 (ESSER III) to fund 7941 (CARES Ed Stabilization). These transfers were made move payroll disbursement activity for reimbursement. Support for these adjustments was traced to School Corporation’s records to verify the Gross Payroll activity moved for all but one transaction, which totaled $27,824. The supporting documentation for this transaction exceeded the amount of the transaction. Inquiry with School Corporation officials and review of the documentation determined that the amount transferred in this transaction was based on the remaining grant budget amounts in the grant fund 7941. The transaction was not based on actual payroll disbursements as all other transfer adjustments were. The $27,824 without supporting documentation is considered questioned costs. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: For future transfers of payroll disbursements, both the Treasurer and Grant Director will ensure that the amount transferred corresponds to actual, documented payroll expenses and not an aggregate salary and/or benefit expenditure. The Chief Financial Officer shall review and approve these transfers to ensure compliance. Anticipated Completion Date: Immediate

View Audit 296034 Questioned Costs: $1

Finding 382353 (2023-006)

Material Weakness 2023

Lake Ridge Schools

IN

Internal Control / Segregation of Duties Special Tests & Provisions Material Weakness § 200.303

FINDING 2023-006 Information on the federal program: Subject: Title I Grants to Local educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies CFDA Numbe...

FINDING 2023-006 Information on the federal program: Subject: Title I Grants to Local educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies CFDA Number: 84.010 Federal Award Numbers and Years (or Other Identifying Numbers): S010A210014, SA10A20014 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Special Tests and Provisions - Annual Report Card, High School Graduation Rate Audit Finding: Material Weakness Contact Persons Responsible for Corrective Action: Regin Johnson, Title I Director Chris Bajmakovich, Principal Calumet HS Contact Phone Number and Email Address: (219) 838-1819 rjohnson@lakeridgeschools.net cbajmakovich@lakeridgeschools.net Condition: An effective internal control system, which would include segregation of duties,was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Annual Report Card, High School Graduation compliance requirement. Context: One individual was involved in collecting the High School student documentation for withdrawal, reviewing the documentation, and removing the student from the cohort. Other review of knowledgeable individual was not documented to ensure all students that were removed from the graduation cohort, had the appropriate documentation to do so. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The high school principal shall review and approve withdrawal documentation collected by the registrar prior to the removal of the student from the graduation cohort. Anticipated Completion Date: Immediate

View Audit 296034

Finding 382351 (2023-005)

Material Weakness 2023

Lake Ridge Schools

IN

Internal Control / Segregation of Duties Eligibility Material Weakness § 200.303 § 200.77 § 200.78

FINDING 2023-005 Information on the federal program: Subject: Title I Grants to Local Educational Agencies - Eligibility Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies CFDA Number: 84.010 Federal Award Numbers and Years or Other Identifying Numb...

FINDING 2023-005 Information on the federal program: Subject: Title I Grants to Local Educational Agencies - Eligibility Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies CFDA Number: 84.010 Federal Award Numbers and Years or Other Identifying Numbers: S010A210014, SA10A20014 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Regin Johnson, Title I Director Contact Phone Number and Email Address: (219) 838-1819 rjohnson@lakeridgeschools.net Condition: This finding addresses two issues. First, an effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirement. Second, The School Corporation has established a process of receiving and reviewing the listing of students from the Private Schools in order to be entered into the Title I application. However, the internal controls were determined not effective since the School Corporation only requested to receive eligible students listing and not enrolled students. Context: The School Corporation has not established a process of review of the Eligibility Summary in the Title I application for the student enrollment and poverty. Real time report October 1 count is used for the eligibility summary in the Title I application. Additionally, the examiner could not determine if the enrolled private school number was correct because the School Corporation did not request the information. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Title I Director will review and sign off on the Real Time October 1 report to ensure that the student enrollment and poverty numbers reconcile with what is submitted in the Eligibility Summary. Additionally, the Title I Director will solicit both eligible and total enrollment figures from private schools that wish to participate in Title I. Anticipated Completion Date: The Corrective Action will be implemented immediately and completed upon the filing of the next Real Time report and Eligibility Summary.

View Audit 296034

Finding 382343 (2023-004)

Material Weakness 2023

Lake Ridge Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Cash Management § 200.303

FINDING 2023-004 Information on the federal program: Subject: Child Nutrition Cluster - Reporting Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children, Fresh Fruit and Vegetable Program Assistanc...

FINDING 2023-004 Information on the federal program: Subject: Child Nutrition Cluster - Reporting Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children, Fresh Fruit and Vegetable Program Assistance Listings Numbers: 10.553, 10.555, 10.559, 10.582 Federal Award Number and Year (or Other Identifying Numbers): FY2021-2022, FY2022-2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Contact Person Responsible for Corrective Action: Chris Akers, Treasurer Contact Phone Number and Email Address: (219) 838-1819 cakers@lakeridgeschools.net Condition: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting noncompliance related to the monthly sponsor claim for reimbursement. Context: School Food Authority’s (SFA) and sponsors must submit monthly claims for reimbursement for meals and snacks served to eligible students within 60 days following the last day of the month covered by the claim. The Food Service Management Company employed Food Service Director prepared the monthly claim for reimbursement on the Indiana Department of Education Child Nutrition Program website based on meal count reports from the point-of-sale system. The School Corporation did not implement a system of internal control to ensure what was claimed for reimbursement agreed to the point-of-sale system meal count reports. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Before the monthly claim for reimbursement is submitted by the FSMC, the Treasurer will reconcile the claim with the meal count report generated by the point-of-sale system. Anticipated Completion Date: Immediate

View Audit 296034

Finding 382335 (2023-003)

Material Weakness 2023

Lake Ridge Schools

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.303 § 200.403 § 200.421 § 200.445 § 200.467

FINDING 2023-003 Information on the federal program: Subject: Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program fo...

FINDING 2023-003 Information on the federal program: Subject: Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children, Fresh Fruit and Vegetable Program Assistance Listings Numbers: 10.553, 10.555, 10.559, 10.582 Federal Award Number and Year (or Other Identifying Numbers): FY2021-2022, FY2022-2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Adrian Wilkerson, Chief Financial Officer Contact Phone Number and Email Address: (219) 838-1819 awilkerson@lakeridgeschools.net Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Activities Allowed or Unallowed and the Allowable Costs/Cost Principles. Context: The School Corporation had not designed or implemented a system of internal control to ensure that program costs incurred by the Food Service Management Company were supported by proper documentation and were allowable. The School Corporation entered into a cost reimbursement contract with a food service management company (FSMC). The FSMC incurred costs and invoiced the School Corporation for reimbursement of the costs. Due to the lack of effective internal controls, the following errors were noted: In a test of 44 items, 22 items (50%) totaling $6,641 did not have proper documentation to support that the expenses were allowable and for the benefit of food service. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: In addition to the monthly review of the FSMC invoice and budget, the Chief Financial Officer will review and approve the supporting documentation (invoices, payroll records) provided by the FSMC to ensure that expenses are allowable and for the benefit of food service. Anticipated Completion Date: Immediate

View Audit 296034 Questioned Costs: $1

Finding 382328 (2023-001)

None 2023

Lbb Corp.

RI

Cash Management HUD Housing Programs Internal Control / Segregation of Duties

Finding 2023-001: late deposit of residual receipts. Corrective action plan: none required.

View Audit 296026

Finding 382322 (2023-004)

Material Weakness 2023

Board of Education Baltimore County

MD

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2023-004 Prior Year Finding: No Federal Agency: U.S. Department of Education Federal Program: Title I, Part A Assistance Listing: 84.010 Pass-Through Entity: Maryland State Department of Education Pass-Through Award Number and Period: 201310-01 (7/1/19 – 9/30/21) 231095-01 (7/1/22 – ...

Finding Number: 2023-004 Prior Year Finding: No Federal Agency: U.S. Department of Education Federal Program: Title I, Part A Assistance Listing: 84.010 Pass-Through Entity: Maryland State Department of Education Pass-Through Award Number and Period: 201310-01 (7/1/19 – 9/30/21) 231095-01 (7/1/22 – 9/30/24) 211116-01 (7/1/20 – 9/30/22) 211303-01 (7/1/20 – 9/30/22) 221499-01 (7/1/21 – 9/30/23) 221769-01 (7/1/21 – 9/30/22) Compliance Requirement: Special Test Type of Finding: Material Weakness in Internal Control over Compliance, Other Matters Recommendation: We recommend that the Board enhance its procedures and internal controls to ensure that it retains documentation to support student withdrawals and that this documentation is available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: BCPS conducts regular training with the school-based staff that maintain this related student documentation. The training will include updates on collecting and maintaining written documentation to meet the requirements for removing a student form the cohort. Name(s) of the contact person(s) responsible for corrective action: Dr. Kim Ferguson, Executive Director of Student Support Services Planned completion date for corrective action plan: For immediate implementation and ongoing.

View Audit 296020

Finding 382297 (2023-001)

Material Weakness 2023

Aids Ministries - Aids Assist of North Indiana, Inc.

IN

Reporting Internal Control / Segregation of Duties

2023-001 Material Adjustments Views of Responsible Officials and Planned Corrective Actions: Prior to the merger of Refresh and AIDS Ministries/AIDS Assist, the financial statements and policies for Refresh were not monitored consistently by previous management/board of directors. Since the merger R...

2023-001 Material Adjustments Views of Responsible Officials and Planned Corrective Actions: Prior to the merger of Refresh and AIDS Ministries/AIDS Assist, the financial statements and policies for Refresh were not monitored consistently by previous management/board of directors. Since the merger Refresh has adopted all financial policies of AIDS Ministries/AIDS Assist. Management will incorporate financial reporting internal controls to detect material adjustments, prevent materially misstated financial statements and increase the accuracy of the interim financial reports used by management for Refresh accounts.

View Audit 296006

Finding 382292 (2023-002)

Significant Deficiency 2023

Contoocook Valley Regional School District

NH

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

Audit Finding Reference: 2023-002 Planned Corrective Action: Review of purchasing policy and federal procurement procedures with grant managers as well as the AP/Grant reporting staff. No purchase will be processed without proper documentation. Name of Contact Person and Completion Date: Brian Cisne...

Audit Finding Reference: 2023-002 Planned Corrective Action: Review of purchasing policy and federal procurement procedures with grant managers as well as the AP/Grant reporting staff. No purchase will be processed without proper documentation. Name of Contact Person and Completion Date: Brian Cisneros (Business Administrator) Anticipated Completion Date – 4/1/24

View Audit 295998 Questioned Costs: $1

Finding 382291 (2023-001)

Significant Deficiency 2023

Contoocook Valley Regional School District

NH

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

Audit Finding Reference: 2023-001 Planned Corrective Action: Onboarding procedure is being changed where employees are not able to start working until a signed contract is on file in their HR file. Name of Contact Person and Completion Date: Brian Cisneros (Business Administrator) Michael Hatfield (...

Audit Finding Reference: 2023-001 Planned Corrective Action: Onboarding procedure is being changed where employees are not able to start working until a signed contract is on file in their HR file. Name of Contact Person and Completion Date: Brian Cisneros (Business Administrator) Michael Hatfield (HR Director) Anticipated Completion Date – 4/1/24

View Audit 295998 Questioned Costs: $1

Finding 382283 (2023-004)

Material Weakness 2023

Ascension Health Alliance D/b/a Ascension

MO

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management

Finding 2023-004 – Reporting Information of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Family Services A...

Finding 2023-004 – Reporting Information of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Family Services Ascension Ministry Market: Illinois Pass-Through Award Number: ARPA000420 Pass-Through Award Period: 05/01/2022-06/30/2023 Pass-Through Grantor: State of Illinois Department of Public Health Ascension Ministry Market: Illinois Pass-Through Award Numbers: 38080717K, 38080718K Pass-Through Award Period: 07/01/2022-06/30/2023 Pass-Through Grantor: Mayor and City Council of Baltimore, Through MONSE Ascension Ministry Market: Maryland Pass-Through Award Number: Not applicable Pass-Through Award Period: 07/01/2022-06/30/2023 Views of responsible officials: Ascension Living management acknowledges that nine reports were not submitted to the State as required by the grant terms. Ascension Living management will coordinate with the State representatives regarding any past reports that are needed and submit them timely according to the agreement requirements. The System implemented a team calendar that tracks due dates of all reports required to be submitted under federal and state programs. This calendar is accessible to all team members, including management. However, Ascension will reinforce the importance to management of oversight and accountability of oversight and accountability to submit required reports. Responsible Official: July Turley, Director of Accounting and Reporting; Rob Madsen, Director of Accounting and Reporting Anticipated completion date: May 31, 2024

View Audit 295994

Finding 382282 (2023-002)

Material Weakness 2023

Ascension Health Alliance D/b/a Ascension

MO

Allowable Costs / Cost Principles Cash Management Period of Performance

Finding 2023-002 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Information of the federal program: Federal Grantor: United States Department of Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Thr...

Finding 2023-002 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Information of the federal program: Federal Grantor: United States Department of Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Family Services Ascension Ministry Market: Illinois Pass-Through Award Number: ARPA000420 Pass-Through Award Period: 05/01/2022-06/30/2023 Pass-Through Grantor: Mayor and City Council of Baltimore, Through MONSE Ascension Ministry Market: Maryland Pass-Through Award Number: Not applicable Pass-Through Award Period: 07/01/2022-06/30/2023 Views of responsible officials: Ascension Living management acknowledges that internal controls were not working effectively regarding review of the calculated limitations and allocations. Ascension has reserved the questioned costs and has communicated with the State on their desired method of repayment. For future grants, Ascension Living will implement controls for appropriate review and approval and to have a secondary review to validate calculations. St. Agnes Healthcare, Inc., Maryland - This finding pertains to retroactive grants where expenses were incurred in previous periods but were subsequently eligible for grant reimbursement. Management is working on creating a report to identify timecards lacking manager approval for exclusion as allowable grant expenses. Grant Accounting is incorporating Time and Effort tracking features a separate approval control to mitigate the issue of timecards lacking manager approval. Responsible Official: July Turley, Director of Accounting and Reporting; Rob Madsen, Director of Accounting and Reporting Anticipated completion date: May 31, 2024, and July 01, 2024

View Audit 295994

Finding 382277 (2023-002)

Significant Deficiency 2023

Bowling Green Independent School District

KY

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

In regard to the 2023-002 COVID-19 Education Stabilization Fund, a payroll record failed to be updated to the new rate per the FY2023 salary schedule and, as a result, extraduty performed by this employee was underpaid by $91 throughout the entirety of FY2023. Management had already identified the i...

In regard to the 2023-002 COVID-19 Education Stabilization Fund, a payroll record failed to be updated to the new rate per the FY2023 salary schedule and, as a result, extraduty performed by this employee was underpaid by $91 throughout the entirety of FY2023. Management had already identified the internal control error in August of 2023, identified the root cause of the error, and had implemented both preventative and detective controls as of August 2023. The controls will be adhered to with the strictest of oversight. If the Kentucky Department of Education has questions regarding this plan, please call Shaunna Cornwell

View Audit 295993

Finding 382269 (2023-005)

Material Weakness 2023

Rensselaer Central School Corporation

IN

Equipment & Real Property Management Internal Control / Segregation of Duties § 200.313

Finding 2023-005 Information on the federal program: Subject: Education Stabilization Fund – Equipment and Real Property Management Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Ent...

Finding 2023-005 Information on the federal program: Subject: Education Stabilization Fund – Equipment and Real Property Management Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Equipment and Real Property Management Audit Findings: Material Weakness  Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management Requirements compliance requirements. Context: During the testing of equipment acquisitions, it was noted the School Corporation is maintaining and updating property records, however, had not performed a physical inventory of capital assets during the period under audit. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. The Rensselaer Central Schools Corporation will hire a firm to perform a physical inventory. Responsible Party and Timeline for Completion: The Treasurer, Dawn Claussen, will oversee the correction plan which will be implemented by June 30, 2024

View Audit 295986

Finding 382259 (2023-002)

Material Weakness 2023

Rensselaer Central School Corporation

IN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303

Finding 2023-002 Information on the federal program: Subject: Special Education Cluster – Suspension and Debarment Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.173 Fede...

Finding 2023-002 Information on the federal program: Subject: Special Education Cluster – Suspension and Debarment Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.173 Federal Award Numbers and Years (or Other Identifying Numbers): 20611-047-PN01, 21611-047-PN01, 22611-047-PN01, 20619-047-PN01, 21619-047-PN01, 22619-047-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the program grant agreements and the compliance requirements related to suspension and debarment. Context: The School Corporation is a member of the Cooperative School Services (Cooperative) and serves as the fiscal agent for the Cooperative. The Cooperative operated the special education programs on behalf of the School Corporation and managed the special education grant funds. As the grant agreement was between the Indiana Department of Education and the School Corporation, the School Corporation was responsible for compliance with the grant agreement and the Suspension and Debarment compliance requirements. During fiscal year 2022, The School Corporation did not have adequate internal controls in place to ensure the Cooperative complied with the suspension and debarment requirements. The Special Education Director obtained suspension and debarment certifications for contracted vendors over $25,000 without an oversight or review process. The lack of controls over suspension and debarment requirements was isolated to fiscal year 2022. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Two Cooperative School Service employees will check and initial the procurement and Suspension and Debarments documentation. Management of the School Corporation will request supporting documentation from Cooperative School Services to validate procurement and suspension and debarment procedure where performed to satisfy federal regulations. Responsible Party and Timeline for Completion: The corrective action plan has been put into place by both parties. Sarah Claton, Director of Cooperative Schools Services and the Treasurer, Dawn Claussen, will oversee the corrective action plan.

View Audit 295986

Finding 382253 (2023-004)

Material Weakness 2023

Plymouth Community School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.302 § 200.303 § 200.328

FINDING 2023 - 004 Finding Subject: COVID-19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or de...

FINDING 2023 - 004 Finding Subject: COVID-19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. During the audit period the School Corporation was required to submit two ESSER I reports, two ESSER II reports, and two ESSER III reports—a total of six reports. However, the School Corporation failed to submit all six required reports. We recommended that management of the School Corporation establish a proper system of internal controls and develop policies and procedures to ensure reports are submitted. Contact Person Responsible for Corrective Action: Steven Boyer Contact Phone Number and Email Address: 574-936-3115 sboyer@plymouth.k12.in.us Views of Responsible Officials: The Corporation concurs with the finding. Description of Corrective Action Plan: The transition in the Corporation’s Business Manager position resulted in a failure to properly identify and train the person responsible for submitting final expenditure reports for ESSER grants. The Business Manager will prepare the final expenditure reports, and the Grant Specialist will review and compare the report to the ledger to verify that it is correct. After the review, the Business Manager will submit the final expenditures reports. Additionally, the Business Manager and Grant Specialist have developed a shared calendar that includes all report due dates. Anticipated Completion Date: This corrective action plan was implemented beginning February 2024 and will be implemented moving forward.

View Audit 295985

Finding 382246 (2023-003)

Material Weakness 2023

Plymouth Community School Corporation

IN

School Nutrition Programs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2023 - 003 Finding Subject: Child Nutrition Cluster – Internal Controls Summary of Finding: The School Corporation had not properly designed or implemented an effective system of internal controls, which would include segregation of duties, that would likely be effective in preventing, or de...

FINDING 2023 - 003 Finding Subject: Child Nutrition Cluster – Internal Controls Summary of Finding: The School Corporation had not properly designed or implemented an effective system of internal controls, which would include segregation of duties, that would likely be effective in preventing, or detecting and correcting, material noncompliance over eligibility and suspension and debarment. We recommended that management of the School Corporation design and implement a proper system of internal control, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place. Contact Person Responsible for Corrective Action: Steven Boyer Contact Phone Number and Email Address: 574-936-3115 sboyer@plymouth.k12.in.us Views of Responsible Officials: The Corporation concurs with the finding. Description of Corrective Action Plan: As part of month-end procedures and the documents sent to the Business Manager, the Food Services Director will include the list of students newly certified for free or reduced meals from CNPweb, Indiana’s portal for the Child Nutrition Program. The Food Services Director will also include the list of students newly certified for free or reduced meals from NutriKids. The Business Manager will review and verify the list when balancing the food program’s monthly receipts, expenditures, and reimbursements. Before contracts are awarded to vendors, the Food Services Director shall use SAM.gov to verify that vendors have not been suspended or disbarred from contracting with Indiana public schools. The Business Manager shall review and verify that the vendors have not been suspended or disbarred, and once verified, contracts will be awarded. Anticipated Completion Date: The Food Services Director and Business Manager have collaboratively reviewed and modified the month-end procedures to ensure that they prevent, detect, and correct eligibility errors, and the new procedures were implemented for February 2024 and will be used for subsequent months.

View Audit 295985

Finding 381233 (2023-004)

Significant Deficiency 2023

County of Orange, California

CA

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

2023-004 Program: COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Federal Financial Assistance Listing Number: 93.391 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: 2022 Com...

2023-004 Program: COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Federal Financial Assistance Listing Number: 93.391 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: 2022 Compliance Requirements: Allowable Activities and Allowable Costs and Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the 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: During our testing of the Health Care Agency’s (HCA) compliance with allowable activities and allowable costs and cost principles requirements, we noted for one (1) of forty-seven (47) transactions HCA did not retain evidence of the review and approval over the transaction. Cause: The transaction was with a specific vendor that requires orders to be placed on the vendor’s portal. At the time the order was placed, the vendor’s portal did not have a system control set up to require a separate approver for the order and HCA did not retain any other evidence to document the order’s review and approval. The vendor portal was later updated during the year to add the segregation of duties system control. Effect: The County’s control was not consistently followed, which requires transactions to be reviewed and approved by a separate individual prior to payment. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of forty-seven (47) of two hundred thirty-six (236) transactions were selected for HCA. The condition above was identified during our testwork of the HCA’s internal controls over allowable activities and allowable costs and cost principles. Repeat Finding from Prior Years: No. Recommendation: We recommend the HCA adhere to their policies and ensure the review and approval of transactions are clearly documented prior payment. Management Response and Corrective Action: Health Care Agency: 1. Person Responsible: Hieu Nguyen, HCA Office of Population Health and Equity Director 2. Corrective Action Plan: HCA Office of Population Health and Equity will implement procedures that ensure review/approval of the e-commerce transactions are documented prior to payment. 3. Anticipated Implementation Date: April 1, 2024

View Audit 295958

Finding 381232 (2023-003)

Significant Deficiency 2023

County of Orange, California

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2023-003 Program: COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health and Healthcare Crises Federal Financial Assistance Listing Number: 93.391 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: 2022 Co...

2023-003 Program: COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health and Healthcare Crises Federal Financial Assistance Listing Number: 93.391 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: 2022 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the 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: During our testing of the Health Care Agency’s (HCA) compliance with reporting requirements, we noted for four (4) of four (4) reports the department did not retain evidence of the review and approval over the performance report. Cause: HCA personnel prepared program required performance reports and submitted the reports without retaining documented evidence that the reports were reviewed and approved by a separate individual prior to submission. Effect: The County did not document their review and approval of the report. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: The entire population of four (4) reports were selected for reporting testwork from HCA. Repeat Finding from Prior Years: No. Recommendation: We recommend the HCA to implement policies that ensure the review and approval of reports are clearly documented prior to the report’s submission. Management Response and Corrective Action: Health Care Agency: 1. Person Responsible: Hieu Nguyen, HCA Office of Population Health and Equity Director 2. Corrective Action Plan: HCA Office of Population Health and Equity will implement procedures that ensure review/approval prior to report submission to the Center for Disease Prevention and Control. 3. Anticipated Implementation Date: April 1, 2024

View Audit 295958

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