Corrective Action Plans

Finding 370511 (2023-001)

Significant Deficiency 2023

Owensboro Health, Inc.

KY

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

Corrective Action already completed in 2023

View Audit 292127

Finding 370506 (2023-002)

Material Weakness 2023

Metropolitan School District of Decatur Township

IN

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

FINDING 2023-002 Finding Subject: Emergency Connectivity Fund – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related t...

FINDING 2023-002 Finding Subject: Emergency Connectivity Fund – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: 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, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The School Corporation completed reimbursement requests and submitted them online; however, there was no evidence of an oversight or review process to ensure that the reimbursement requests were for allowable activities, allowable costs, and within the period of performance. Contact Person Responsible for Corrective Action: Derek Coulombe, Director of Technology Contact Phone Number and Email Address: (317) 856-5265; dcoulombe@decaturproud.org Views of Responsible Official: We concur with Audit Finding Description of Corrective Action Plan: The School Corporation will develop procedures to ensure disbursement requests are printed out and a representative from the Business Department documents review of them for allowable activity before final submission. Anticipated Completion Date: March 1, 2024

View Audit 292091

Finding 370500 (2023-001)

Significant Deficiency 2023

Goddard College Corporation

VT

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.90

The College has controls and processes in place to properly evaluate credit (SAP). As part of the corrective action we have documented and re-trained the Registrar and financial aid staff on the process to record SAP; notify the student of probationary periods; and notify financial aid of a change i...

The College has controls and processes in place to properly evaluate credit (SAP). As part of the corrective action we have documented and re-trained the Registrar and financial aid staff on the process to record SAP; notify the student of probationary periods; and notify financial aid of a change in SAP status. The process has an additional section that establishes segregation of duties such that a member of the Registrar’s office shall not update their own record but would request posting be reviewed and completed by another member of the registrar’s office. The documentation of this process is included below: 1. At the beginning of each semester the Registrar’s office will evaluate credit (SAP) on the prior semester. In order to ensure proper segregation of duties the following section has been added. • If a member of the Registrar’s office is a student during the prior semester a different member of the Registrar’s office will evaluate their SAP and update their record. • Any notification related to the evaluation of SAP will be conducted by the other Registrar’s office member. 2. The Registrar’s office will notify financial aid of students without credit. • The Financial Aid Office will provide appropriate notifications for students who did not receive credit (SAP) for the first time. 3. The Registrar’s office will evaluate if lack of credit (SAP) is for a second semester. • If it is the second semester, the student is then notified and they are no longer eligible for federal financial aid for the upcoming term. • The Financial Aid office will provide notification to the student that credit is needed for that semester or the student is not eligible for federal financial aid for the upcoming term. • The Registrar’s office will provide notification of students on the list created in point 2 and 3 to the Financial Aid office. 4. Financial Aid will update student’s record to indicate that they are ineligible for financial aid. This process will remain in place until Goddard College completes implementation of “Anthology Student” which is an integrated student information system that supports compliance with Title IV guidelines. Anthology will evaluate satisfactory academic progress against an approved program, among many other compliance items, and provide the integrated notification to students of their lack of progress as well as flag their financial aid record so that federal funds are not approved. This system will replace the intensive manual data management process currently utilized and the electronic alerts and processes will achieve results reliably and automatically. The college would like to note that the registrar (the student in question) did not provide written notification that she did not meet SAP from the Fall term but she was aware of it given her position and normal job duties. The employee involved has submitted their resignation from the college and the process will be shared with the new Registrar. Financial aid staff has completed additional training on SAP guidelines and the importance of compliance with SAP requirements.

View Audit 292086

Finding 370491 (2023-002)

Significant Deficiency 2023

Hamline University of Minnesota

MN

Student Financial Aid Reporting Significant Deficiency

Department of Education 2023-002 Student Financial Assistance – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are b...

Department of Education 2023-002 Student Financial Assistance – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are being reported timely. Explanation of disagreement with audit finding: There is no disagreement with the auditfinding. Action taken in response to finding: Auditors identified five students where the change in enrollment status was not reported in a timely manner. It was noted that we identified the status changes while there was a cybersecurity breach within the file transfer system used by the National Student Clearinghouse (NSC), our third-party servicer. As a result, our reporting was delayed. We received notice of the incident from the NSC on June 16, 2023. Our next planned transmission was scheduled for June 28. We postponed our regular reporting schedule for one week while we reset our secure FTP password with NSC, initialized our account in their updated system, and while our ITS security officer evaluated the risk. We ended up submitting the file to the NSC on July 5. As a result of this incident, we remain vigilant for external factors that may impact our reporting schedule. We will address them as quickly as possible to avoid reporting delays. Names of the contact persons responsible for corrective action: Gwenn Sherburne, Registrar Planned completion date for corrective action plan: By first reporting date for 2023-2024 academic year in early September 2023.

View Audit 292076

Finding 370485 (2023-001)

None 2023

Moses H Cone Memorial Hospital Operating Corporation, Inc.

NC

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

We have revised the calculation of the Paid Annual Leave award and verified that it uses the pay rates in effect at the time of the award for all employees. We confirmed that no other expenses for the COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (“Provider Relief ...

We have revised the calculation of the Paid Annual Leave award and verified that it uses the pay rates in effect at the time of the award for all employees. We confirmed that no other expenses for the COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (“Provider Relief Fund”) reporting involved costs subject to similar point in time report parameters. The change to this cost item does not impact the full utilization of the Provider Relief Fund due to the presence of other expenses in the same category along with unreimbursed expenses and unused lost revenues remaining after the funds were exhausted. The discrepancy was due to imprecise instructions in the request for information. In the future, such ad hoc requests and the responsive reports will be verified by the Executive Director of Corporate Accounting before use.

View Audit 292044 Questioned Costs: $1

Finding 370473 (2023-005)

Material Weakness 2023

East Porter County School Corporation

IN

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

Finding 2023-005 – Special Education Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-508-0504 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Dir...

Finding 2023-005 – Special Education Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-508-0504 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Director of Business Affairs & HR will work with the Special Education Coop to ensure compliance with the Procurement and Suspension and Debarment requirement. Anticipated Completion Date: February 2024

View Audit 292036

Finding 370465 (2023-004)

Significant Deficiency 2023

East Porter County School Corporation

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

Finding 2023-004 – Special Education Cluster – Earmarking Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-508-0504 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Director of Business Affairs & H...

Finding 2023-004 – Special Education Cluster – Earmarking Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-508-0504 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Director of Business Affairs & HR will work with the Special Education Coop to ensure compliance with the Earmarking requirement. Anticipated Completion Date: February 2024

View Audit 292036

Finding 370462 (2023-003)

Material Weakness 2023

East Porter County School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

Finding 2023-003 – Child Nutrition Cluster – Special Tests and Provisions – Verification of Free and Reduced Price Applications Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-508-0504 Views of Responsible Official: We concur with the finding. Descrip...

Finding 2023-003 – Child Nutrition Cluster – Special Tests and Provisions – Verification of Free and Reduced Price Applications Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-508-0504 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: As an internal control, the Director of Business Affairs and Human Resources has reviewed the process for Verification of Free and Reduced Price Applications. We have now contracted with a Food Service Director through NIESC. They will perform the Verification of Free and Reduced Price Applications and the Director of Business Affairs & HR will review these documents for accuracy. Anticipated Completion Date: FY24 Verification of Free and Reduced Price Application Review Period

View Audit 292036

Finding 370459 (2023-002)

Significant Deficiency 2023

East Porter County School Corporation

IN

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

Finding 2023-002 – Child Nutrition Cluster – Reporting Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-508-0504 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: As an internal control, the Food Service...

Finding 2023-002 – Child Nutrition Cluster – Reporting Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-508-0504 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: As an internal control, the Food Service Manager or Director of Food Service will prepare the reimbursement claim and the Director of Business Affairs and HR or Treasurer will review and initial the claims. This will ensure the accuracy of the reimbursement claim. Anticipated Completion Date: This Corrective Action was put into place in September 2022 following our prior audit. The Claim that was not signed for this Audit was from October 2021.

View Audit 292036

Finding 370453 (2023-008)

Material Weakness 2023

One City Schools, Inc.

WI

School Nutrition Programs Subrecipient Monitoring Internal Control / Segregation of Duties

Recommendation: Internal controls for accounting for nonprofit school food service funds should be implemented. A separate class in the accounting software for the program could be utilized. Action Taken: One City Schools developed a new financial class for School Nutrition, and all grant funds and ...

Recommendation: Internal controls for accounting for nonprofit school food service funds should be implemented. A separate class in the accounting software for the program could be utilized. Action Taken: One City Schools developed a new financial class for School Nutrition, and all grant funds and expenditures will be classed to School Nutrition so these funds are clearly segregated from others. One City Schools implemented these new class designations as of January 1, 2024. Additionally, OCS added relevant tasks in our monthly accounting procedures to check for miscodes and ensure grant funds and expenditures are correctly coded.

View Audit 292020

Finding 370449 (2023-007)

Material Weakness 2023

One City Schools, Inc.

WI

Questioned Costs Subrecipient Monitoring School Nutrition Programs § 200.302 § 200.334

Recommendation: One City Schools, Inc. should design and implement appropriate internal controls for retaining support for claims in accordance with federal requireents. Action Taken: One City Schools has developed a new process to document meal counts per month, attendance and enrollment numbers pe...

Recommendation: One City Schools, Inc. should design and implement appropriate internal controls for retaining support for claims in accordance with federal requireents. Action Taken: One City Schools has developed a new process to document meal counts per month, attendance and enrollment numbers per month, submission of claims, and the signature of a designated second approver, the COO. As each claim is made, the associated backup documentation will be presented to the second approver for their review and signature. Once approved, the entire packet of information will be retained. This process was initiated in December 2023.OCS completed the second designated approver review retroactively for all claims in the months of July, September, October, and November 2023.

View Audit 292020 Questioned Costs: $1

Finding 370445 (2023-006)

Material Weakness 2023

One City Schools, Inc.

WI

Subrecipient Monitoring School Nutrition Programs Matching / Level of Effort / Earmarking § 200.303

Recommendation: One City Schools, Inc. should design and implement appropriate internal controls for reviewing funding claims. Action Taken: One City Schools has developed a new process for submission where a second approver, the COO, reviews the claims for accuracy. This process started in December...

Recommendation: One City Schools, Inc. should design and implement appropriate internal controls for reviewing funding claims. Action Taken: One City Schools has developed a new process for submission where a second approver, the COO, reviews the claims for accuracy. This process started in December 2023, however OCS also completed this second approver review retroactively for all claims in July 2023, September 2023, October 2023, and November 2023.

View Audit 292020

Finding 370430 (2023-002)

Significant Deficiency 2023

Bloomfield College

NJ

Student Financial Aid Reporting Significant Deficiency

Bloomfield College and Affiliates respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 01, 2022 - June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with t...

Bloomfield College and Affiliates respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 01, 2022 - June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2023-002 Student Financial Assistance Cluster – Federal Assistance Listing Numbers 84.268 & 84.063 Recommendation: We recommend that the College strengthen its policies and procedures toensure that student disbursement records are submitted accurately to the COD within 15 dayof disbursements being made to students’ accounts, and that the College maintain clear evidence that a secondary review is performed to verify that the submission was made timelyAction taken in response to finding: The error was identified prior to the end of the award year and the student’s award was corrected. The award was posted and disbursed prior to the return of the revised ISIR into the system. To ensure that accurate information is being used for awards, the Financial Aid office will strengthen its process to review changes and updates to a student’s FASFA prior to disbursing funds. This will ensure that disbursements are submitted accurately to COD with 15 days of the disbursements being made to the student’s accounts. Immediate processing and policy changes with the staff have been implemented. Contact person responsible for corrective action: Quincina Littlejohn, Director of Financial Aid973-748-9000 ext. 1211 Planned completion date for corrective action plan: The corrective action date was December 2023. The new procedures were put into effect immediately.

View Audit 292012

Finding 370428 (2023-001)

Significant Deficiency 2023

Bloomfield College

NJ

Student Financial Aid Special Tests & Provisions Eligibility

Bloomfield College and Affiliates respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 01, 2022 - June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with t...

Bloomfield College and Affiliates respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 01, 2022 - June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2023-001 Student Financial Assistance Cluster – Federal Assistance Listing Numbers 84.268 & 84.063 Recommendation: The College should strengthen policies and procedures to ensure that student status transmission reports are submitted accurately to the NSLDS at least every 60 days, or more often, as determined to be appropriate. The College also should ensure that student Published Program Length Measurements are listed in years and that the Published Program Lengths are calculated in years as recommended by the NSLDS Enrollment Reporting Guide so that the Published Program Length calculation is accurate to the true length of the program for each student. Action taken in response to finding: The College has updated its policies and procedures in overseeing submissions to NSLDS by the third-party servicer “National Student Clearinghouse.” The Registrar’s office, Enterprise Information Services, and the Financial Aid office will work together to ensure that relevant information is reported accurately and timely by “NSC” in accordance with applicable regulations. Contact persons responsible for corrective action: Aylin Solu-Brandon, University Registrar, 973-655-7525 Planned completion date for corrective action plan: We implemented the corrective action in January 2024. Following a discussion with the staff about the finding, new processing procedures were promptly implemented. The College will ensure that student Published Program Length Measurements are listed in years and that the published Program Lengths are calculated in years.

View Audit 292012

Finding 370424 (2023-002)

Significant Deficiency 2023

Pacific University

OR

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303 § 200.332 § 200.501

Pacific University acknowledges the importance of an effective control environment and closely monitors activities of subrecipients under federal awards. Pacific was able to demonstrate that the selected subrecipients had appropriate audits under Subpart F (or were not subject to such audits). Howe...

Pacific University acknowledges the importance of an effective control environment and closely monitors activities of subrecipients under federal awards. Pacific was able to demonstrate that the selected subrecipients had appropriate audits under Subpart F (or were not subject to such audits). However, the University will enhance controls related to tracking such compliance

View Audit 291993

Finding 370421 (2023-001)

Significant Deficiency 2023

Pacific University

OR

Internal Control / Segregation of Duties Student Financial Aid Subrecipient Monitoring § 200.303 § 200.403

Pacific University acknowledges the importance of an effective control environment. University policies do require approval of all timesheets. Management will re-emphasize the importance of this key approval control and periodically review supervisor compliance (with follow-up on exceptions). The ap...

Pacific University acknowledges the importance of an effective control environment. University policies do require approval of all timesheets. Management will re-emphasize the importance of this key approval control and periodically review supervisor compliance (with follow-up on exceptions). The approval requirement will also be added to Pacific’s mandatory annual compliance training for supervisors.

View Audit 291993

Finding 370413 (2023-003)

Significant Deficiency 2023

Central Virginia Partnership for Economic Development

VA

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

Cost Allocations: The Organization concurs with the finding. The employee responsible for the change did not seek proper approval. The Organization will communicate the circumstances to the recipient of the federal awards so they may update their procedures as necessary.

View Audit 291991

Finding 370412 (2023-002)

Significant Deficiency 2023

Central Virginia Partnership for Economic Development

VA

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

Segregation of Duties: The Organization concurs with the findings. The Organization has determined it is staffed appropriately given the resources available and will continue to look for new opportunities to address these findings.

View Audit 291991

Finding 370401 (2023-001)

Significant Deficiency 2023

St. Catherine University

MN

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure all status changes are updated with the appropriate timef...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure all status changes are updated with the appropriate timeframe as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: When we learned that the procedures didn't accurately explain the terms that needed to be reported, we updated them. We will include students who graduated from the prior term as well as the current term when needed, to ensure all graduates are included. Name(s) of the contact person(s) responsible for corrective action: Kerri Vickers Planned completion date for corrective action plan: October 2023

View Audit 291976

Finding 370359 (2023-008)

Material Weakness 2023

City of Detroit, Michigan

MI

Subrecipient Monitoring Material Weakness Reporting § 200.302 § 200.303

Finding Number: 2023‐008 Federal Program, Assistance Listing Number and Name: ALN 14.241, Department of Department of Housing and Urban Development, Housing Opportunities for Persons with AIDS (HOPWA) and COVID‐19 HOPWA Condition: Original Finding Description: The controls in place were not adequate...

Finding Number: 2023‐008 Federal Program, Assistance Listing Number and Name: ALN 14.241, Department of Department of Housing and Urban Development, Housing Opportunities for Persons with AIDS (HOPWA) and COVID‐19 HOPWA Condition: Original Finding Description: The controls in place were not adequate to ensure that amounts reported within the CAPER were accurate and complete in relation to activity reported in the general ledger and underlying records of the City. Contact Person Responsible for Corrective Action: Regina Greear (ODFS), Cynthia Saxton (OGA) and Julie Schneider (HRD) Anticipated Completion Date: June 2023 Planned Corrective Action: The City will review during the AFCAP process and implement additional reporting controls that includes verification of expenditures, retention of supporting documentation and a timely final reconciliation of the CAPER Report to the general ledger.

View Audit 291959

Finding 370355 (2023-007)

Material Weakness 2023

City of Detroit, Michigan

MI

Questioned Costs Subrecipient Monitoring Eligibility § 200.303

Finding Number: 2023-007 Federal Program, Assistance Listing Number and Name: ALN 14.241, Department of Department of Housing and Urban Development, Housing Opportunities for Persons with AIDS (HOPWA) and COVID‐19 HOPWA Condition: Original Finding Description: In conjunction with eligibility testing...

Finding Number: 2023-007 Federal Program, Assistance Listing Number and Name: ALN 14.241, Department of Department of Housing and Urban Development, Housing Opportunities for Persons with AIDS (HOPWA) and COVID‐19 HOPWA Condition: Original Finding Description: In conjunction with eligibility testing, instances of noncompliance specific to the rental assistance calculation and distribution of benefits were identified. Contact Person Responsible for Corrective Action: Denise Fair Razo (DHD) and Angelique Tomsic (DHD) Anticipated Completion Date: June 2023 Planned Corrective Action: City of Detroit HOPWA program has a dedicated quality coordinator position. The coordinator will continue to work closely with the HOPWA program team and conduct regular file audits. The HOPWA program team has also implemented additional steps which includes the use of eligibility templates to help ensure accurate rental assistance calculations. In addition, the City will review during the AFCAP process to ensure the required process improvements and procedures are in place for accurate rental assistance calculations.

View Audit 291959 Questioned Costs: $1

Finding 370340 (2023-006)

Material Weakness 2023

City of Detroit, Michigan

MI

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

Finding Number: 2023‐006 Federal Program, Assistance Listing Number and Name: ALN 21.027, Department of Treasury, COVID‐19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Condition: Original Finding Description: The payroll costs that were reported as incurred on four CSLFRF projects were...

Finding Number: 2023‐006 Federal Program, Assistance Listing Number and Name: ALN 21.027, Department of Treasury, COVID‐19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Condition: Original Finding Description: The payroll costs that were reported as incurred on four CSLFRF projects were incorrect in the performance report submitted for the period October 1, 2022, through December 31, 2022 (Quarter 4). Contact Person Responsible for Corrective Action: Terri Daniels (ODG) Anticipated Completion Date: June 2023 Planned Corrective Action: The City will review during the AFCAP process and implement additional controls to ensure the quarterly Treasury reports align with the expenses as stated on the general ledger.

View Audit 291959

Finding 370331 (2023-003)

Material Weakness 2023

City of Detroit, Michigan

MI

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Finding Number: 2023‐003 Federal Program, Assistance Listing Number and Name: ALN 10.557, Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Condition: Original Finding Description: The City did not have adequate controls in place to exercise its ...

Finding Number: 2023‐003 Federal Program, Assistance Listing Number and Name: ALN 10.557, Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Condition: Original Finding Description: The City did not have adequate controls in place to exercise its oversight responsibility of eligibility determinations that were performed by a contractor for the program. Contact Person Responsible for Corrective Action: Denise Fair Razo (DHD) Anticipated Completion Date: Complete May 2023 Planned Corrective Action: The City has implemented controls to ensure that the Health Department provides oversight over the contractors. In May 2023, the Health Department hired a WIC Program Director to monitor participant eligibility compliance and ensure policies and procedures are maintained and followed.

View Audit 291959

Finding 370321 (2023-003)

Significant Deficiency 2023

Natrona County, Wyoming

WY

Allowable Costs / Cost Principles Cash Management Internal Control / Segregation of Duties

2023-003 Cash Management Program Health Care for the Homeless Name of Contact Person Kelly Wessels, Executive Director Corrective Action Plan • CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal...

2023-003 Cash Management Program Health Care for the Homeless Name of Contact Person Kelly Wessels, Executive Director Corrective Action Plan • CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. o All fiscal transactions are entered into Sage, and all backup is uploaded at the time of requested transaction. o This is then sent to the Approver, who then reviews for reasonable, allocable and allowable costs. o Payment requests cannot be submitted and forwarded electronically if the backup is not uploaded and the requestor electronically initials that they did so. Approvers are assigned in work flows and transactions are reviewed by Supervisor, Fiscal Department personal o Reimbursement requests are reviewed at program level, compliance officer level and fiscal and presented to Executive Director to review with backup before submitted for reimbursement. Sage houses all backup receipts etc. o All journal entries have time stamps in software and identify who/when the entry occurred and a field is provided to explain the “why”, with reference(s). • Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. • Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: o Internal controls o Allowable compensation and employee benefits o Cost allocation methods o Governing body financial responsibilities o Budgeting o Financial reporting o Financial management systems o Documentation and record retention o Financial policies and procedures o Allowable costs • All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. Proposed Completion Date June 30, 2024

View Audit 291948

Finding 370320 (2023-002)

Material Weakness 2023

Natrona County, Wyoming

WY

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

2023-002 Activities Allowed or Unallowed and Allowable Costs/Costs Principles Program Community Services Block Grant Name of Contact Person Kelly Wessels, Executive Director Corrective Action Plan As of July 1, 2023 the following behaviors and standards were implemented: • CAPNC moved from an archa...

2023-002 Activities Allowed or Unallowed and Allowable Costs/Costs Principles Program Community Services Block Grant Name of Contact Person Kelly Wessels, Executive Director Corrective Action Plan As of July 1, 2023 the following behaviors and standards were implemented: • CAPNC moved from an archaic, unsupported software system to Sage Intaact. This software provides the ability to modernize and deploy the levels of internal controls missing from previous fiscal personnel oversight and technical capability. Current staff have trained under Sage Intaact and Wipfli consultants to properly track A/P, A/R, payroll and grant management to ensure the integrity of data entry and compliance is observed. Board membership have access to accounting software through Board portal for further oversight. • Payroll services were outsourced to ADP payroll services in order to provide real time features and accountability for time. This allows recording of time more accurate, reliable and allocable. Payroll records are reviewed and time studies are being performed for all staff to ensure allocation methodology, once selected is appropriate, consistent and in alignment with staff performance. o Time entry occurs electronically in real time; hourly employees are assigned a schedule, and salaried staff are monitored o Time cards are electronically submitted and approved electronically to ensure time is recorded as it occurs. o Time off records are also submitted for approval electronically and leave is approved based on County personnel guidance. • Wipfli Consulting is providing technical assistance over a 10 month period to develop/deploy updated policies and procedures for fiscal area, in accordance with Uniform Guidance. Curriculum includes: o Internal controls o Allowable compensation and employee benefits o Cost allocation methods o Governing body financial responsibilities o Budgeting o Financial reporting o Financial management systems o Documentation and record retention o Financial policies and procedures o Allowable costs • All administrative leadership staff received, and will continue to receive annually, fiscal oversight training including but not limited to, Uniform Guidance training, grants management and compliance training. Allocations are reviewed regularly by leadership team to ensure that we have appropriate methodology and that we are consistent with grant expectations and regulations. Proposed Completion Date June 30, 2024

View Audit 291948 Questioned Costs: $1

Corrective Action Plans

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