Corrective Action Plans

Finding 390267 (2023-004)

None 2023

TX

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Due to turnover and transitions in key positions, on-boarding of agencies did not include these three locations on the annual site visit schedule. In FY 2024 new procedures have already been implemented for on-boarding, new personnel have been assigned oversight of agencies, and two compliance depar...

Due to turnover and transitions in key positions, on-boarding of agencies did not include these three locations on the annual site visit schedule. In FY 2024 new procedures have already been implemented for on-boarding, new personnel have been assigned oversight of agencies, and two compliance departments, one in Accounting and one in Partner Services, have been fully established to monitor compliance.

View Audit 301154

Finding 390260 (2023-103)

Material Weakness 2023

Maricopa County Community College District

AZ

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

Assistance Listing number and name: 84.031 Higher Education – Institutional Aid Award numbers and years: P031S160090, October 1, 2016 through September 30, 2023 P031S190167, October 1, 2019 through September 30, 2024 P031S200096 and P031S200081, October 1, 2020 through September 30, 2025 P031C2...

Assistance Listing number and name: 84.031 Higher Education – Institutional Aid Award numbers and years: P031S160090, October 1, 2016 through September 30, 2023 P031S190167, October 1, 2019 through September 30, 2024 P031S200096 and P031S200081, October 1, 2020 through September 30, 2025 P031C210057 and P031C210077, October 1, 2021 through September 30, 2026 P031S220015 and P031S220179, October 1, 2022 through September 30, 2027 Federal Agency: U.S. Department of Education Compliance Requirements: Reporting and special tests and provisions Questioned costs: Unknown Name of contact persons: Kristina Winterstein, Associate Controller, District Business Services Diana Aguirre-Rosales, Fiscal Director, Maricopa Community Colleges Foundation Anticipated completion date: December 31, 2024 The District is aware of the importance of ensuring that reports submitted are reviewed for accuracy prior to submission and implemented new processes for report review and submission in November 2023. On February 7, 2024, after multiple requests, the U.S. Department of Education (ED) provided the District with access to ED’s reporting system, which will allow the District to timely submit reports. The District will coordinate with the Maricopa Community Colleges Foundation to ensure that the endowment contracts include all necessary federal regulation information and that the investment and disbursement of funds are in accordance with federal regulations.

View Audit 301142 Questioned Costs: $1

Finding 390255 (2023-101)

Material Weakness 2023

Maricopa County Community College District

AZ

Questioned Costs Student Financial Aid Special Tests & Provisions § 200.303

Cluster Name: Student Financial Assistance Cluster Assistance Listing number and name: 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study Program 84.038 Federal Perkins Loan Program-Federal Capital Contributions 84.063 Federal Pell Grant Program 84.268 Fed...

Cluster Name: Student Financial Assistance Cluster Assistance Listing number and name: 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study Program 84.038 Federal Perkins Loan Program-Federal Capital Contributions 84.063 Federal Pell Grant Program 84.268 Federal Direct Student Loans Award Year: July 1, 2021 through June 30, 2022 Federal Agency: U.S. Department of Education Compliance Requirements: Special tests and provisions Questioned Costs: Unknown Name of Contact Persons: Joshua Lindenberg, District Director of Financial Aid Anticipated Completion Date: December 31, 2024 The Maricopa County Community College District understands the importance of reporting accurate student enrollment statuses and all student enrollment status changes to the National Student Loan Database (NSLDS) for the Pell and Direct Loan programs. System improvements were completed in June 2023 to reduce and prevent enrollment reporting errors. The District will continue to enhance internal controls by expanding procedures to proactively monitor, detect, and correct unresolved enrollment reporting errors and will conduct semi-annual quality assurance reviews of student accounts to ensure enrollment data is reported appropriately to the NSLDS. The district will assess and enhance the existing enrollment reporting transmission schedule, documenting and disseminating a final copy to staff to ensure optimal efficiencies and reduce enrollment reporting errors caused by the timing of data transmission and error processing.

View Audit 301142 Questioned Costs: $1

Finding 390252 (2023-002)

Significant Deficiency 2023

Kvc Health Systems, Inc.

KS

Cash Management Reporting Internal Control / Segregation of Duties

KVC Hospitals, Inc. - Effective Internal Controls related to the Financial Statements Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The Organization is going to continue and improve its understanding of the guidance related to this type of reporting and ...

KVC Hospitals, Inc. - Effective Internal Controls related to the Financial Statements Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The Organization is going to continue and improve its understanding of the guidance related to this type of reporting and work with their external advisors to ensure future portal submissions are compliant with said guidance. Going forward, the Organization will continue to improve its internal controls related to lost revenue calculations and reporting and work with their external advisors to ensure future portal submissions, if any, are compliant with said guidance. The under-reporting of lost revenues had no impact on the Organization’s ability to cover the total Provider Relief Fund payments received. This review will be performed by June 30, 2024. Responsible Official: Sherri Lohe Chief Financial Officer

View Audit 301134

Finding 390236 (2023-003)

Significant Deficiency 2023

National University

CA

Procurement, Suspension & Debarment Eligibility Significant Deficiency

Finding 2023-003 – Eligibility – Significant Deficiency in Internal Control over Compliance Management acknowledges the audit finding and wants to reinforce that despite challenges in the cost of attendance; there were no over or under-awards to students. To address this finding, our Quality Assuran...

Finding 2023-003 – Eligibility – Significant Deficiency in Internal Control over Compliance Management acknowledges the audit finding and wants to reinforce that despite challenges in the cost of attendance; there were no over or under-awards to students. To address this finding, our Quality Assurance team will oversee a weekly review of the cost of attendance to ensure financial aid packages align with approved budgets, enabling early identification of discrepancies for prompt correction. Based on these reviews, individual and group coaching will be implemented to address areas of concern. A refresher training and updated tools and guidance will be completed to reinforce best practices and align with institutional policy and procedure for calculating the cost of attendance. Through these concerted efforts, NU hopes to demonstrate its full commitment to addressing the audit findings. Contact Person Responsible for Corrective Action: Brandy Baker, Director of Quality Assurance Angela De Angelini, AVP Processing and Fiscal Operations Anticipated Completion Date: June 2024

View Audit 301132

Finding 390235 (2023-002)

Material Weakness 2023

National University

CA

Student Financial Aid Material Weakness Reporting

Finding 2023-002 - Special Tests and Provisions – Enrollment Reporting: Material Weakness in Internal Control Management agrees with this finding. The institution proposes a multifaceted approach aimed at resolving the root causes of the inaccuracies and preventing their recurrence. National Univer...

Finding 2023-002 - Special Tests and Provisions – Enrollment Reporting: Material Weakness in Internal Control Management agrees with this finding. The institution proposes a multifaceted approach aimed at resolving the root causes of the inaccuracies and preventing their recurrence. National University has implemented regular reviews of its enrollment reporting. During this process, errors in reporting are identified and corrected. However, the timing of the review has not allowed enough time to process corrections within compliance. To allow for appropriate adjustments and corrections to be implemented after testing but before the enrollment reporting deadline, National University will shift the timing of its enrollment reporting review from 60 to 30 days. Though NU is currently testing enrollment reporting and adjusting queries in an ongoing effort to improve accuracy, some of those adjustments inadvertently caused students to not appear in our queries. This impact on reporting occurred in edge cases not taken into account in the queries. To ensure this does not happen in the future, NU will implement a testing regime for these queries. This testing will be conducted at regular intervals to verify the effectiveness and accuracy of the queries in identifying students who have ceased attendance as required. Through these concerted efforts, NU hopes to demonstrate its full commitment to addressing the audit findings. We know that these efforts will take time to fully take effect and be reflected in future audits. Contact Person Responsible for Corrective Action: Brandy Baker, Director of Quality Assurance and Sarah Massey, AVP Operations, Student Support and Registrar Anticipated Completion Date: June 2024

View Audit 301132

Finding 390234 (2023-001)

Material Weakness 2023

National University

CA

Internal Control / Segregation of Duties Special Tests & Provisions Student Financial Aid

Management’s Corrective Action Plan National University acknowledges the findings and the recommendations regarding improving procedures. Finding 2023-001 - Special Tests and Provisions – Return of Title IV: Material Weakness in Internal Control National University agrees with this finding. As we c...

Management’s Corrective Action Plan National University acknowledges the findings and the recommendations regarding improving procedures. Finding 2023-001 - Special Tests and Provisions – Return of Title IV: Material Weakness in Internal Control National University agrees with this finding. As we continue to refine our R2T4 processes, we’ve had two key challenges we are addressing: Timeliness of R2T4 calculations: In FY22, NU identified an issue with how it was identifying unofficial withdrawals at the institution. To assist in rectifying the issue, we implemented a 35-day attendance policy that resulted in a significant amount of students being attritted from the University. We were working with a third-party firm to help us complete all the R2T4 calculations, which proved challenging; between our internal staffing and external support, we did not have the ability to do all of the calculations timely. As we’ve analyzed the needed manpower, we’ve expanded our Processing and Quality Assurance teams. The establishment of two additional teams within the Processing team in 2024 underscores our commitment to ensuring the timely completion of necessary calculations. Simultaneously, the increased Quality Assurance team is poised to support the enhanced internal controls, conducting weekly reviews of R2T4 calculations to verify their accuracy and timeliness. Missing students for R2T4 calculations who were withdrawn: We have established precise and accurate criteria for the development and execution of report queries. This initiative aims to ensure the comprehensive identification of students who discontinue attendance before the end of a payment period, thereby mitigating the risk of oversight. To bolster the reliability of these refined processes, NU is committed to implementing regular testing of the attendance queries. By conducting these tests at established intervals, the institution seeks to verify that the queries consistently identify the correct cohort of students. This approach serves as a crucial mechanism to maintain the accuracy of our withdrawal determination processes and underscores our dedication to continuous improvement. Through these concerted efforts, NU hopes to demonstrate its full commitment to addressing the audit findings. We know that these efforts will take time to fully take effect and be reflected in future audits. Contact Person Responsible for Corrective Action: Brandy Baker, Director of Quality Assurance Angela De Angelini, AVP Processing and Fiscal Operations Anticipated Completion Date: June 2024

View Audit 301132

Finding 390231 (2023-003)

Significant Deficiency 2023

Rider University

NJ

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

Federal Perkins Loan Program – Assistance Listing No. 84.038 Recommendation: We recommend the University implement a procedure with the third party servicer to ensure that their report is completed timely so that the University can perform the necessary due diligence they need to perform. Explanat...

Federal Perkins Loan Program – Assistance Listing No. 84.038 Recommendation: We recommend the University implement a procedure with the third party servicer to ensure that their report is completed timely so that the University can perform the necessary due diligence they need to perform. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Recognizing the importance of resolving this finding the University intends to adjust policies and procedures around reviewing the third-party servicer processes around regulations and compliance items therein. Name(s) of the contact person(s) responsible for corrective action: Miranda Cole, Director and Tristan Schmittinger, Associate Director. Planned completion date for a corrective action plan: 3/26/2024

View Audit 301124

Finding 390230 (2023-002)

Significant Deficiency 2023

Rider University

NJ

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: CLA recommends the University review its policies and procedures around sending exit counseling information to students to ensure students are receiving proper counseling. Explanation of disagreement with audit finding: T...

Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: CLA recommends the University review its policies and procedures around sending exit counseling information to students to ensure students are receiving proper counseling. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: In addition to the University’s automated procedures, Financial Aid and the Registrar will reconcile the finalized listing of graduates for each semester to confirm that all students are receiving exit counseling requirements and ensure proper counseling is provided to students. Name(s) of the contact person(s) responsible for corrective action: Miranda Cole, Director and Tristan Schmittinger, Associate Director. Planned completion date for a corrective action plan: 3/19/2024

View Audit 301124

Finding 390228 (2023-001)

Significant Deficiency 2023

Rider University

NJ

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Federal Pell Grant Program, Federal Direct Student Loans – Assistance Listing No. 84.063, 84.268. Recommendation: We recommend the University review procedures around sending the correct information to the NSLDS. In addition, we recommend the University develop a process to help better oversee the ...

Federal Pell Grant Program, Federal Direct Student Loans – Assistance Listing No. 84.063, 84.268. Recommendation: We recommend the University review procedures around sending the correct information to the NSLDS. In addition, we recommend the University develop a process to help better oversee the submissions completed by the third-party servicer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Registrar's Office can confirm the National Student Clearing House (NSC) enrollment history for all two students is accurate. It appears that there have been challenges with the National Student Loan Data System (NSLDS) receiving current data from NSC in a timely manner. We take action to ensure that we will work with Financial Aid and crossreference the Registrar's monthly submission report and/or weekly Withdrawal Report with an NSLDS' report provided by Financial Aid to address any discrepancies. We will also work with the NSC audit team to ensure if there are any other processes, that we can implement on our end to better oversee the submission with our third-party servicer (NSC). Name(s) of the contact person(s) responsible for corrective action: Justina Nicita, Assistant Registrar, and Miranda Cole, Director of Financial Aid. Planned completion date for a corrective action plan: 3/19/2024.

View Audit 301124

Finding 390227 (2023-003)

Significant Deficiency 2023

Do Good Multnomah

OR

Reporting Significant Deficiency Internal Control / Segregation of Duties

The finance team has been expanded and with the guidance of a nonprofit finance consultant additional roles are set to be established so that invoices can be prepared by someone other than the approver. In the immediate interim, invoices will be reviewed and signed by the CEO before submission by th...

The finance team has been expanded and with the guidance of a nonprofit finance consultant additional roles are set to be established so that invoices can be prepared by someone other than the approver. In the immediate interim, invoices will be reviewed and signed by the CEO before submission by the CFO.

View Audit 301123

Finding 390226 (2023-002)

Significant Deficiency 2023

Do Good Multnomah

OR

Allowable Costs / Cost Principles Cash Management Reporting

We have implemented additional levels of approval and oversight for point-of-sale and invoice spending to ensure that receipts are captured and retained correctly, and that at invoices are reviewed and approved before payment. We have also provided additional training for spenders on best practices ...

We have implemented additional levels of approval and oversight for point-of-sale and invoice spending to ensure that receipts are captured and retained correctly, and that at invoices are reviewed and approved before payment. We have also provided additional training for spenders on best practices of recording and maintaining records. We have since also consolidated our supply chain so that spenders are able to procure most supplies through one vendor, which will have reporting and tracking capabilities. We will also be making significant changes to how mileage reimbursement is documented and approved.

View Audit 301123

Finding 390225 (2023-001)

Material Weakness 2023

Do Good Multnomah

OR

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

The finance team has been expanded and with the guidance of a nonprofit finance consultant additional roles are set to be established so that there is support to be able to be able to adequately review and approve invoices, as well as train and hold accountability with supervisors for payroll approv...

The finance team has been expanded and with the guidance of a nonprofit finance consultant additional roles are set to be established so that there is support to be able to be able to adequately review and approve invoices, as well as train and hold accountability with supervisors for payroll approval.

View Audit 301123

Finding 390219 (2023-004)

Material Weakness 2023

Enlace Chicago

IL

Procurement, Suspension & Debarment Eligibility Material Weakness

Procurement Recommendation: We recommend that the Organization follow the current policies and procedures over covered transactions to maintain documentation supporting the procurement for 5 years following the end of the contract. Views of Responsible Officials: There is no disagreement with this ...

Procurement Recommendation: We recommend that the Organization follow the current policies and procedures over covered transactions to maintain documentation supporting the procurement for 5 years following the end of the contract. Views of Responsible Officials: There is no disagreement with this finding. Action taken in response to finding: Enlace Chicago is committed to following the procurement process and requirements outlined within the policies and procedures. Name of the contact person responsible for corrective action: Laura Velazquez, Director of Finance Planned completion date for corrective action plan: June 30, 2024.

View Audit 301111

Finding 390204 (2023-006)

Significant Deficiency 2023

Iberville Parish School Board

LA

Procurement, Suspension & Debarment Equipment & Real Property Management Matching / Level of Effort / Earmarking

The Superintendent, Iruis Voiron, Jt, has mandated that all contracts entered into by the District follour the Uniform Guidance for federal procurement. The exact langu€e has been shared with staff and is being used in all contracts.

View Audit 301105

Finding 390198 (2023-001)

Significant Deficiency 2023

St. Lukes Health Network, Inc. and Controlled Entities

PA

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

2023-001 – Gaps in General Controls for SFA/COD Process (Significant Deficiency) Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal ...

2023-001 – Gaps in General Controls for SFA/COD Process (Significant Deficiency) Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell Grant Program and Federal Direct Student Loans Assistance Listing Numbers: 84.063 and 84.268 Award Year: 2022-2023 Pass-through entity: Not applicable The Network has controls for the student financial aid program, monitored by the Student Financial Aid Office. The Network agrees with the finding regarding the retention of support and documentation of the reviews and approvals in the financial aid process. Going forward the Network will enhance the documentation and retention of support of proper review and approval that will evidence the appropriate segregation of duties. The Network is implementing this process beginning in Q4 of FY2024. For inquiries regarding this finding, please contact Lisa Storck, Senior Associate Dean, and Joe Zelasko, Senior Financial Aid Coordinator, who are responsible for the corrective action.

View Audit 301103

Finding 390168 (2023-002)

Material Weakness 2023

Altus Independent School District #18

OK

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking

Altus Public Schools plans to meet the requirements of the Davis-Bacon Act on any future federal awards. Weekly payroll reports will be reviewed with vendors to ensure that federal rates and fringes are met. Items will be posted at the work site to ensure compliance with the Davis-Bacon Act.

View Audit 301082

Finding 390167 (2023-001)

Material Weakness 2023

Altus Independent School District #18

OK

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking

Altus Public Schools plans to meet the requirements of the Davis-Bacon Act on any future federal awards. Weekly payroll reports will be reviewed with vendors to ensure that federal rates and fringes are met. Items will be posted at the work site to ensure compliance with the Davis-Bacon Act.

View Audit 301082

Finding 390163 (2023-005)

Material Weakness 2023

Yukon Flats School District

AK

Cash Management Material Weakness Reporting

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calenda...

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calendar developed by ALASBO which addresses all reporting requirements for the school districts in Alaska. Proposed Completion Date: March 31, 2024

View Audit 301080

Finding 390157 (2023-002)

Significant Deficiency 2023

City of Daly City

CA

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

Finding Reference Number: SA2023-002 Documenting Payroll Costs Charged to Grant Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Departm...

Finding Reference Number: SA2023-002 Documenting Payroll Costs Charged to Grant Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-22-MC-06-0010 COVID-19 - B-20-MW-06-0010 • Fiscal Year of Initial Finding: 2023 • Name(s) of the contact person: Betsy ZoBell, Housing and Community Development Manager • Corrective Action Plan: ECD staff will perform periodic review of estimates to confirm that payroll allocations are supported by timesheet documentation of actual hours worked. • Anticipated Completion Date: 06/30/24

View Audit 301060

Finding 390151 (2023-002)

Significant Deficiency 2023

Vermont Adult Learning, Inc.

VT

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

Finding # 2023 -002 Issue: During our audit procedures we identified instances where there was no documented rate approval or pay rate support within personnel files. Pay rates and pay rate changes should be reviewed and approved by department supervisors and human resource director at the time o...

Finding # 2023 -002 Issue: During our audit procedures we identified instances where there was no documented rate approval or pay rate support within personnel files. Pay rates and pay rate changes should be reviewed and approved by department supervisors and human resource director at the time of pay changes and documented in personnel files. Root Cause: The Organization is not properly following the internal controls in place over the documentation of such pay rate changes. Corrective Action Plan: ● The Organization has discussed internally how to more accurately and efficiently submit, sign and record pay rates and pay rate changes. The Human Resources department, as well as all supervisors are dedicated to retaining accurate and complete personnel records. The Organization will send each employee a letter when their raise comes up that documents their old rate and new rate. This letter will be signed by the employee, then the Supervisor, as well as the HR Director. Once all three signatures are obtained, HR will send a final, signed copy to the supervisor, and will keep a copy in a secure, central location that is accessible to the Supervisors and Directors. Timeline: This will be implemented as soon as possible Person Responsible for Corrective Action Plan: Joe Przyperhart, Program Director/Interim Executive Director, David Justice, Program Director/Interim Executive Director, Human Resources Director, Grant Managers and Regional Directors will oversee changes to ensure all payroll rate changes are reviewed, approved and appropriately filed in a secure location.

View Audit 301059

Finding 390147 (2023-001)

Significant Deficiency 2023

Vermont Adult Learning, Inc.

VT

Procurement, Suspension & Debarment Significant Deficiency Matching / Level of Effort / Earmarking

Finding # 2023-001 Issue: During our audit procedures we identified instances where there was no documented approval of invoices over expense transactions. Expenses should be reviewed and approved by someone other than the purchaser. Root Cause: The Organization is not properly following the in...

Finding # 2023-001 Issue: During our audit procedures we identified instances where there was no documented approval of invoices over expense transactions. Expenses should be reviewed and approved by someone other than the purchaser. Root Cause: The Organization is not properly following the internal controls in place over the approval of such expense transactions. Corrective Action Plan: We are committed to ensuring that we have approval of all expense transactions. To that end we have: ● VAL implemented procedures that all expenses must be accompanied by a purchase approval form for approval before the payment occurs. The purchase approval form is initiated by the purchaser, then signed by a manager or director and is submitted with the invoice or credit card receipt to Bill.com (A/P) or Dext (CC transactions) for payment and/or documentation retention. Multiple levels of additional approval are documented and retained in Bill.com (A/P). Purchases through vendor websites also include a level of approval (for example Staples and Amazon). In these cases, staff create an order and submit it for approval. The order is not processed until the Office Administrator approves every order. Invoices from these vendors still go through the regular approval process. There is just an extra layer of approval to ensure accuracy in reporting. ● Recurring expenses - The purchase approval process is also initiated for the initial payment of a recurring expense, noting that the expense will be a recurring charge. When expenses occur after the initial expense, any documentation related to the expense will be saved, but no approval form is required for future expenses as long as the amount or coding doesn’t change. This includes, but is not limited to, monthly lease payments, job search subscriptions, parking subscriptions, health/dental/vision/FSA expenses, etc. Timeline: This updated process has been implemented as of April 2023. Staff and management have been more diligent regarding including purchase approval forms to all expenses incurred. VAL has also verified that all expenses are reviewed for accuracy by managers, directors, and the outsourced accounting firm. Person Responsible for Corrective Action Plan: Joe Przyperhart, Program Director/Interim Executive Director, David Justice, Program Director/Interim Executive Director, Grant Managers and Regional Directors will oversee changes to ensure all expenses include the appropriate approval documentation.

View Audit 301059

Finding 390146 (2023-002)

Material Weakness 2023

Health Care for All, INC

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Given the Organization’s lack of experience with federal awards, Management was not familiar with the accounting requirements for expenses allocated to federal grant programs. In particular, there was a lack of familiarity with respect to the limitations on indirect cost rate application on subreci...

Given the Organization’s lack of experience with federal awards, Management was not familiar with the accounting requirements for expenses allocated to federal grant programs. In particular, there was a lack of familiarity with respect to the limitations on indirect cost rate application on subrecipient disbursements. Moving forward, management will ensure that it properly allocate expenses in accordance with Uniform Guidance Regulations. In addition, management plans to work closely with the federal passthrough entity to ensure that overbilled amounts are returned during the fiscal year ending June 30, 2024

View Audit 301052 Questioned Costs: $1

Finding 390145 (2023-001)

Significant Deficiency 2023

Health Care for All, INC

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with the Uniform Guidance. This exercise is anticipated to be complete by the end of the fiscal year.

View Audit 301052

Finding 390138 (2023-002)

Material Weakness 2023

Barnes-Kasson County Hospital

PA

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2023-002 Condition The Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Hospital erroneously entered information into the lost revenue calculation, resulting in lost revenues being understated $1,020,0...

Finding 2023-002 Condition The Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Hospital erroneously entered information into the lost revenue calculation, resulting in lost revenues being understated $1,020,030. The Hospital reported lost revenues amounting to $999,172 on distributions totaling $1,177,041. The Hospital had excess lost revenues from previous periods available to be used through June 30, 2023 amounting to $5,406,884. The Hospital also reported expenses of $907,051. Corrective Action Plan Corrective Action Planned: The Hospital will undertake a review of its internal control policies and procedures surrounding the reporting on federal grant activities and add additional layers of review where necessary to ensure future reporting is accurate. Name of Contact Person Responsible for Corrective Action: Kelli Kane, Chief Financial Officer Anticipated Completion Date: April 15, 2024

View Audit 301031

Corrective Action Plans

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