Corrective Action Plans

Finding 46334 (2022-028)

Material Weakness 2022

WV

Questioned Costs Special Tests & Provisions Eligibility § 200.303

SPECIAL TESTS AND PROVISIONS ? INCOME ELIGIBILITY AND VERIFICATION SYSTEM Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 The Income and Eligibility Verification System (IEVS) provides the DHHR Bureau for Family Assistance (the Bureau) with sources...

SPECIAL TESTS AND PROVISIONS ? INCOME ELIGIBILITY AND VERIFICATION SYSTEM Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 The Income and Eligibility Verification System (IEVS) provides the DHHR Bureau for Family Assistance (the Bureau) with sources of information for use in determining eligibility and the amount of the benefit for applicants and recipients. Procedures established to assist in the prevention of fraud and abuse in the form of computer matches are utilized. The social security number of the applicant or recipient is matched against the files from the West Virginia Bureau of Employment Programs, the Internal Revenue Service, and the Social Security Administration (SSA). The State Online Query (SOLQ) provides direct access to SSA?s databases. Information received includes SSN verification; Supplemental Security Income (SSI); and Retirement, Survivors, and Disability Insurance (RSDI) details. Requests can be made only for individuals known to the eligibility system within the previous five years. The Bureau?s Policy Unit will collaborate with the Bureau?s Division of Professional Development to create a more detailed and precise training for the IEVS System. The blackboard platform will allow supervisors to track workers that have completed the training. The anticipated date for completion is June 30, 2023. Furthermore, the Policy Unit will send out various IEVS Policy Reminders and will work to revise the IEVS User Guide.

View Audit 40967

Finding 46333 (2022-027)

Material Weakness 2022

State of West Virginia

WV

Special Tests & Provisions Questioned Costs Matching / Level of Effort / Earmarking § 200.303

INTERNAL CONTROLS OVER SPECIAL TESTS AND PROVISIONS ? CHILD SUPPORT NON-COOPERATION, PENALTY FOR REFUSAL TO WORK, AND ADULT CUSTODIAL PARENT OF CHILD UNDER SIX WHEN CHILD CARE NOT AVAILABLE Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 The WV WOR...

INTERNAL CONTROLS OVER SPECIAL TESTS AND PROVISIONS ? CHILD SUPPORT NON-COOPERATION, PENALTY FOR REFUSAL TO WORK, AND ADULT CUSTODIAL PARENT OF CHILD UNDER SIX WHEN CHILD CARE NOT AVAILABLE Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 The WV WORKS Policy Unit within the DHHR Bureau for Family Assistance will continue to send out reminders and Sanction Flowchart/Desk Guides to staff. The bureau?s Policy Unit will work with the bureau?s Division of Professional Development regarding the continued use of Blackboard Courses and Virtual Training. The WV WORKS Council will add a ?Sanction Workshop? to Payment Accuracy Conferences; the anticipated date for completion is August 31, 2023. Finally, the Policy Unit will continue to review RAPIDS Management Reports monthly regarding third level sanctions to ensure the sanctions are being sent to the Policy Unit for review and approval.

View Audit 40967

Finding 46291 (2022-023)

Material Weakness 2022

State of West Virginia

WV

Questioned Costs Equipment & Real Property Management Matching / Level of Effort / Earmarking § 200.303

ALLOWABILITY Bluefield State University, Glenville State University, and Mountwest Community and Technical College Assistance Listing Number 84.425E, 84.425F, 84.425J, 84.425M Bluefield State University (BSU) response P425F200727 $19,882?BSU agrees with the finding that these were routine maintena...

ALLOWABILITY Bluefield State University, Glenville State University, and Mountwest Community and Technical College Assistance Listing Number 84.425E, 84.425F, 84.425J, 84.425M Bluefield State University (BSU) response P425F200727 $19,882?BSU agrees with the finding that these were routine maintenance costs that, which would mitigate the spread of COVID, would have been incurred by the University in any event. BSU has put in place procedures to review all future use of funds to be certain that are specifically related to COVID mitigation. P425J200063?BSU believes the questioned costs in this finding were allowable. At the time BSU made the draw for the costs, BSU based the decision on FAQ #23 and used the definition of minor remodeling. This wall is within a previously completed functioning building, and does not structurally alter the building, therefore, BSU deemed it to be remodeling. Due to the overall cost of the wall in comparison to the market value of the building BSU deemed it to be minor. As stated in 34 CFR ? 77.1, ?[m]inor remodeling means minor alterations in a previously completed building? and also includes the extension of utility lines, such as water and electricity, from points beyond the confines of the space in which the minor remodeling is undertaken but within the confines of the previously completed building.? The response to Question #24 of the FAQ provides some additional guidance and specific examples of permissible ?minor remodeling? that may be paid for with HEERF grant funds. The remodeling in this case was very similar to the examples of permissible minor remodeling provided in the FAQ. Obtaining the hospital building permitted BSU to offer on-campus housing in a portion of the hospital that was converted into student dormitories. Another part of the building remained in use as a hospital. HEERF funds were used to construct a wall between the dormitory area and the part of the building being used as an Emergency Room. As a result, the construction of the wall in question was ?for purposes associated with the coronavirus? and should be viewed as an eligible HEERF expenditure. The related plumbing and electrical work should also be viewed as a permissible expenditure given the reference in the response to FAQ #24 to ?the extension of utility lines, such as water and electricity, from points beyond the confines of the space in which the minor remodeling is undertaken but within the confines of the previously completed building.? As indicated previously, at the time the decision to use HEERF fund for the construction of the wall, prior approval was not required. The project in question can be fairly characterized as a minor alteration in a previously completed building for the purposes of preventing the spread of COVID-19. For all of the reasons discussed above, BSU respectfully maintains that the construction of the wall in question and the related electrical and plumbing work should be viewed as an eligible expenditure. P425E200618: BSU believes awards were made in good faith and according to the regulations, as described below. However, BSU proposes the following corrective action plan to mitigate the issue. BSU used $305,191 of institutional funds to make emergency grants to students that the auditors agree meet the definition in the FAQs. These grants were based solely on the number of credits the students were enrolled in during the term or were to pay for books for students who requested assistance. BSU proposes to reimburse the Institutional funds for those grants from the above amount drawn. That would leave a balance of $1,291,079 in dispute and free up those Institutional funds for upcoming COVID related expenses. Additionally, BSU has HBCU funds that are unspent as of the date of this response. BSU proposes to reimburse the remaining balance of $1,291,079 from the HBCU funds. BSU believes these are valid expenses for HBCU funds. That would return those funds to the Student portion, which would allow BSU to make additional emergency payments to students before the funds expire on June 30, 2023. These questions costs were for grants to students who lived in surrounding counties outside of West Virginia who were given waivers for the tuition above the University?s in-state rate, to student athletes and those with certain levels of academic achievement. In addition to the grants noted above, BSU used the Student Portion of HEERF funds to provide emergency funds to all students, based only on their part-time or full-time status. BSU relied on FAQ #s 11, 12 and 13 in determining that expending the funds was within the proper guidelines. For example, the funds were used for the students? cost of attendance and electronic or written authorization were received to use the funds to satisfy students? account balances. Nearly half of those who received the grants in question were Pell eligible (277 out of 600, or 46%). Similarly, approximately 46.9% of the funds spend on grants in these three categories went to Pell eligible students. Therefore, BSU believes that students with exceptional need were appropriately prioritized in awarding these grants. Out-of-state students faced an added financial burden based on the added cost of out of state tuition. Grants to those students to assist with that cost were not linked to any of the factors identified in the response to FAQ #12 as a basis for determining that an institution failed to prioritize emergency financial grants to students with exceptional need. Grants to out-of-state students were just one avenue of distributing HEERF funds to students, who were free to pursue other avenues of funding. As indicated above, BSU used the Student Portion of HEERF funds to provide emergency funds to all students, based only on part-time or full-time status, which given the high percentage of Pell eligible students attending BSU, reached many students with exceptional need. Due to the high proportion of Pell eligible students who received the grants in question and the high costs faced by the out-of-state students, BSU believes that the grants to out-of-state students did not demonstrate a failure to prioritize students with exceptional need. With respect to students who received grants who participated in athletic programs or demonstrated certain levels of academic performance, BSU notes again the group in question contained a high proportion of Pell eligible students. Funds were available through other means to students other than those participating in athletic programs or demonstrating high levels of academic performance (including but not limited to the out-of-state students discussed above or the emergency funds made available to all students based only on full-time or part-time status that were provided using the Student Portion of HEERF funds). Academic performance or athletic participation were not a prerequisite to receiving any assistance at all, but rather two ways to access assistance. Viewing efforts to provide aid to students as a whole, BSU does not believe that the distribution of HEERF funds demonstrated a failure to prioritize emergency financial aid grants to students with exceptional need. Glenville State University (GSU) response To ensure compliance with all federal reporting guidelines, existing federal time and effort calculation guidelines, along with relevant internal control policies and procedures, will be saved to a shared drive or other location to which the necessary personnel have access. As a best practice, primary consideration will be given for the usage of detailed time sheets or time logs being kept for each GSU employee whose time or effort is partially or wholly allocated to federal grant-related activity. These time sheets/time logs will include the percentage of time spent working on grant-related activities, the percentage of time spent working on non-grant university-related activities, a general description of activities performed for the grant related activity, and the total number of hours worked each week. Time sheets/logs will be reviewed and approved regularly by the grant-funded employee, the employee?s supervisor, and the Grants Compliance Director or designee. In cases for which the time sheet method is not deemed practical to be employed, the Chief Financial Officer or designee will draft a memo that provides a detailed explanation and justification of the method used for calculating time and effort. This memo will be signed by the Chief Financial Officer and the Director of Grants Compliance. On a quarterly basis, the Controller or Chief Financial Officer and Director of Grants Compliance will meet to ensure the relevant documented time and effort matches the corresponding draw down amounts. Mountwest Community and Technical College (MCTC) response Effective February 2022, MCTC enhanced policies and procedures to ensure formal approval and documentation of expenditures for HEERF funds is retained to ensure compliance.

View Audit 40967 Questioned Costs: $1

Finding 46290 (2022-022)

Material Weakness 2022

State of West Virginia

WV

Questioned Costs Student Financial Aid Reporting § 200.303

REPORTING Fairmont State University, West Virginia State University, Bluefield State University, West Virginia Northern Community College, West Liberty University, Southern West Virginia Community and Technical College, Pierpont Community and Technical College, Concord University, Mountwest Communit...

REPORTING Fairmont State University, West Virginia State University, Bluefield State University, West Virginia Northern Community College, West Liberty University, Southern West Virginia Community and Technical College, Pierpont Community and Technical College, Concord University, Mountwest Community and Technical College, and Glenville State University Assistance Listing Number 84.425E, 84.425F, 84.425J, 84.425M Fairmont State University (FSU) response In regard to the Annual Reporting of HEERF, the Controller will work with the Financial Reporting Manager to ensure the annual data is accurate and reflects the data reported on the quarterly reporting for the same period. The Controller will perform data entry of all required fields in the annual submission website. Once complete, an email will be sent to the CFO for final review and approval. The CFO will provide email correspondence that the review is complete and the reporting is approved for submission. The CFO will submit the annual report via the reporting website. This action was implemented January 2023. West Virginia State University (WVSU) response WVSU developed and documented an internal control procedure to ensure compliance of HEERF Reporting. This procedure includes a dual review and sign off process by Business and Finance before the report is posted to WVSU?s website. This review includes ensuring accurate forms are being used for reporting. Additionally, screen captures are saved to provide a date/timestamp of when the report was made public. The control was implemented on or before July 1, 2022. Bluefield State University (BSU) response BSU has strengthened internal controls over reporting of HEERF funds to assure that the posting to the University website in a timely manner is documented in writing. BSU posted all reports to the University website on or before the filing deadline. However, we did not receive written documentation from our IT department to document the timely posting. We have revised our internal control procedures to ensure that that we receive and retain documentation of the posting date. BSU inadvertently used incorrect terminology to describe some of the emergency grants to students made from the Student Portion of HEERF funds. The reports selected for testing were for the Student Portion of funds that was reported in a narrative format. The revised reporting form issued by the Department of Education combines the reporting of Student, Institutional and HBCU funds on one standard form. This will eliminate these types of errors in subsequent reporting. West Virginia Northern Community and Technical College (WVNCC) response WVNCC is aware to include the total amount of grants distributed, the estimation of students to receive a grant and the total amount of students to receive the grant from the calculations used to issue Emergency Financial Aid Grants. In addition to reporting the method used to determine award amounts to students prior to the awards being disbursed, WVNCC will also include the method used in future reporting. As an added layer of review, WVNCC will include a third report reviewer from Student Accounts to verify the number and dollar amount of awards disbursed to be included in the report. This action was implemented in January 2023. West Liberty University (WLU) response As of January 2023, federal drawdowns are reconciled and reviewed prior to the drawdown. The signature of the Controller or CFO is on each drawdown with the date of review and approval. The drawdown is then completed usually on the same date as the review and approval. Southern West Virginia Community and Technical College (SWVCC) response SWVCC has enhanced its procedures surrounding the preparing, updating, and reviewing of quarterly and annual reports for the HEERF Education Stabilization Fund (and all other federal awards). The information utilized to prepare the reports is now dated and saved for future reference. The individual compiling the report documents the date the report is completed and submits it to the reviewer. The reviewer documents the date of review and any adjustments made to the report. The review is completed before the report is posted to the institution?s website and all documentation will be maintained for audit review. These procedures are in place as of January 2023. Pierpont Community and Technical College (PCTC) response PCTC?s staff and administration have reviewed the reporting requirements for HEERF funding to ensure quarterly and annual reports are accurate and timely. All staff involved in the reporting process, which includes the offices of Financial Aid, Registrar and Finance, have been directed to document and retain all source data used in the reporting process. A documented review process was put in place in October 2022 to ensure review by a supervisor and a final review by the Vice President of Finance and Administration/Chief Financial Officer or the Comptroller. Evidence of the review process is demonstrated through sign offs and/or e-mail communications. Concord University (CU) response Beginning with the December 2022 quarterly reporting, the coordination and approval of all reports will continue to be documented electronically. Additionally, the level of review/approval for the generated reports prior to posting will also be documented, and all work orders requesting the public posting of approved reports will include a cited reminder of the federal posting deadline for grant compliance. This additional information in the requested work order will ensure all parties involved are aware of and meet the required posting deadline. These steps were taken for the December 2022 Institutional Portion (CFDA #84.425F) quarterly reporting and resulted in a timely posting. The Student Aid Portion (CFDA #84.425E) final reporting occurred during fiscal year 2022. Mountwest Community and Technical College (MCTC) response For student reporting ? Q4 FY2021 and Q3 FY2022 there were no student reports prepared for these quarters. MCTC submitted OMB Control Number 1840-0849 with no expenditures reflected for HEERF I, II, or III Student Portion for FY21 Quarter 4 and FY 22 Quarter 3. All funds were fully expended by the end of FY 22 Quarter 2. Although there were no HEERF Student Portion funds expensed during the Quarters in question, MCTC has acknowledged that the language on the website should have been updated to disclose all funding as awarded and final. As a response to the finding, MCTC will develop a Quarterly Reporting schedule for posting on the website to capture all awarding activity from HEERF I, II, and III from point of initial receipt of HEERF funds through the grant end period, June 30, 2023. For Institutional Reporting ? Q4 FY2021 institutional report was not posted timely within the 10-day reporting requirement. This occurred before the PY corrective action plan was implemented. A corrective action plan was submitted on February 17, 2022 and all subsequent quarterly reports have been submitted timely. Glenville State University (GSU) response GSU implemented and strengthened internal controls surrounding the reporting for both HEERF II and III in February 2022. GSU has created and filled the position of Director of Grants Compliance. This new Director has direct oversight and assurance of GSU?s compliance with all grant reporting requirements. The Director will prepare and maintain a ?Master? checklist for all grants received by GSU. The checklist will be monitored and updated as reporting or compliance steps are met by the Director. The Director will coordinate with the relevant personnel with reporting or compliance responsibility over the grant to ensure the compliance expectations are met timely.

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Finding 46287 (2022-025)

Significant Deficiency 2022

State of West Virginia

WV

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

TRANSPARENCY ACT REPORTING Department of Education (DOE) Assistance Listing Number 84.425C, 84.425D, 84.425R, 84.425U Program management will implement policies and procedures to ensure that Transparency Act Reporting is conducted with proper reviews. In order to comply with the Federal Funding Acc...

TRANSPARENCY ACT REPORTING Department of Education (DOE) Assistance Listing Number 84.425C, 84.425D, 84.425R, 84.425U Program management will implement policies and procedures to ensure that Transparency Act Reporting is conducted with proper reviews. In order to comply with the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act), as amended by Section 6202(a) of the Government Funding Transparency Act of 2008 (Pub. L. No. 111-252), that relate to sub-award reporting, the DOE Office of Internal Operations will work with each awarding office to ensure the sub-awards have been thoroughly reviewed and signed before reporting each month. This will comply with 2 CFR 200.303 which requires an entity to "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". The timeline for the development and initiation of this process (barring any unforeseen system limitations) is tentatively set for July 1, 2023.

View Audit 40967

Finding 46286 (2022-021)

Material Weakness 2022

State of West Virginia

WV

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

MAINTENANCE OF EFFORT Department of Education (DOE) Assistance Listing Number 84.425C/84.425D/84.425R/84.425U DOE submitted a waiver request in June 2022 and is currently working with the U.S. Education Department to obtain a waiver for Maintenance of Effort for FY22. DOE is also working with the ...

MAINTENANCE OF EFFORT Department of Education (DOE) Assistance Listing Number 84.425C/84.425D/84.425R/84.425U DOE submitted a waiver request in June 2022 and is currently working with the U.S. Education Department to obtain a waiver for Maintenance of Effort for FY22. DOE is also working with the Office of the Governor and Legislative Leaders to review compliance for the 2023 fiscal year.

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Finding 46234 (2022-017)

Significant Deficiency 2022

State of West Virginia

WV

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303

SPECIAL TESTS AND PROVISIONS ? GRAMM-LEACH-BLILEY ACT ? STUDENT INFORMATION SECURITY Fairmont State University and Pierpont Community and Technical College Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 84.408, 93.264, 93.342, 93.364, 93.925 Fairmont State University (FSU...

SPECIAL TESTS AND PROVISIONS ? GRAMM-LEACH-BLILEY ACT ? STUDENT INFORMATION SECURITY Fairmont State University and Pierpont Community and Technical College Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 84.408, 93.264, 93.342, 93.364, 93.925 Fairmont State University (FSU) response FSU entered into a contract with Wolf & Company to perform an external risk assessment for our systems in 2021 but was not completed due to staffing changes until 2022. The external risk assessment was received from Wolf in June 2022. The report and its suggestions were immediately reviewed and approved. This action will be implemented in January 2023 for fiscal year 2023 and will be implemented each July, starting with July 2023, hereafter. It was not understood that annual reviews needed to occur at the beginning of each fiscal year until this finding was received. Pierpont Community and Technical College (PCTC) response In December 2022 and January 2023, PTCT developed the following policies and procedures, which also detail internal controls, relative to the Gramm-Leach-Bliley Act and student information security. ? Access to Security Controlled Spaces Policy ? Anti-Virus Policy ? Backup and Recovery Policy ? Change Management Policy ? Computer Disposal Policy ? Computer Security Policy ? Data Security Policy ? IT Firewall Policy ? IT Incident Response Policy ? System Update Policy ? Mobile Device Use Policy ? Remote Access Policy ? Risk Assessment Policy ? Banner Document Procedure ? Banner Security Procedure ? Argos Access Procedure ? Active Directory Security and User Creation ? National Student Loan Clearinghouse Enrollment Submission Procedure ? National Student Loan Clearinghouse Graduate Only Submission Procedure ? Nelnet Refunds Procedure ? Risk Assessment Procedure Risk assessments will now be performed two times a year and will follow the Risk Assessment Procedure. This procedure also incorporates all policies, procedures, and internal controls as the framework for the ensuring of student information security.

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Finding 46232 (2022-015)

Material Weakness 2022

State of West Virginia

WV

Questioned Costs Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303

SPECIAL TESTS AND PROVISIONS - VERIFICATION Bluefield State University, Fairmont State University, and Pierpont Community and Technical College Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 84.408, 93.264, 93.342, 93.364, 93.925 Bluefield State University (BSU) response...

SPECIAL TESTS AND PROVISIONS - VERIFICATION Bluefield State University, Fairmont State University, and Pierpont Community and Technical College Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 84.408, 93.264, 93.342, 93.364, 93.925 Bluefield State University (BSU) response Effective January 2023, after all calculations are made and checklists are completed the files will be reviewed by another counselor for accuracy. This reviewer will sign off on the file and checklist that it has been reviewed and no errors were found or recalculation needed. Both the preparer and the reviewer will sign off and date the checklist. Fairmont State University (FSU) response Controls were put into place in 2020-2021 to address the additional review of the verification process once the initial review was completed. FSU found that through some reporting and timing that the additional review did not occur for all students. FSU will implement a weekly review with a comprehensive review monthly to ensure no students are missed through the additional review process in February 2023. Pierpont Community and Technical College (PCTC) response Staff members have been, and will continue to be, prompted to print, scan and keep all documentation pertaining to verifications. In these two cases, the counselor did not print the Confirmation page that displays upon completing V4 & V5 verifications in Central Processing System (CPS) and did not follow the flow of placing the verification packet in the appropriate location for second review. PCTC has reviewed policies and procedures and made a slight modification. Beginning with the 22/23 aid year, the Financial Aid Administrator (FAA) brings the completed verification packet to the Director of Financial Aid. The Director then determines who will complete the second review. The second review can be completed by either the Director of Financial Aid, the Assistant Director of Financial Aid or another qualified FAA. Once completed and signed off, the verification packet is place into the permanent individual student?s file.

View Audit 40967 Questioned Costs: $1

Finding 46230 (2022-013)

Significant Deficiency 2022

State of West Virginia

WV

Student Financial Aid Questioned Costs Matching / Level of Effort / Earmarking § 200.303

FISCAL OPERATIONS REPORT AND APPLICATION TO PARTICIPATE Fairmont State University, West Virginia State University, and West Virginia School of Osteopathic Medicine Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 93.264, 93.342, 93.364, 93.925 Fairmont State University (FS...

FISCAL OPERATIONS REPORT AND APPLICATION TO PARTICIPATE Fairmont State University, West Virginia State University, and West Virginia School of Osteopathic Medicine Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 93.264, 93.342, 93.364, 93.925 Fairmont State University (FSU) response As of January 2023, the Financial Reporting Manager will complete Part II of the Fiscal Operations Report and Application to Participate (FISAP) submission. The Controller will review and compare with audited financial statements to ensure the correct amounts are recorded prior to approval and submission by the institution. West Virginia State University (WVSU) response This finding was a result of inaccurate reporting. The dollar amounts used for tuition and fees in the original calculation were incorrect. The supporting documentation was updated after submission of the FISAP to include correct numbers. To prevent this from occurring in the future, a dual review will be required for all reporting data. The Office of Financial Aid and Scholarships will verify the Federal Work-Study (FWS) and Supplemental Education Opportunity Grant (SEOG) fund allocations are identified correctly on the FISAP, in regard to transfer of funds, to accurately reflect the allotted fund amounts and amounts paid to student accounts in Banner. These changes were made effective March 2022 and reflected in the FY22 FISAP. West Virginia School of Osteopathic Medicine (WVSOM) response Internally generated reports used to prepare the FISAP from WVSOM?s management system have been modified to ensure accuracy and clarity of the data. Procedures are in place for a secondary review of the report prior to submission.

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Finding 46227 (2022-010)

Significant Deficiency 2022

State of West Virginia

WV

Questioned Costs Reporting Matching / Level of Effort / Earmarking

REPORTING State of West Virginia (WV) Assistance Listing Number 21.027 Going forward, WV will ensure that all data requested for calculations related to the revenue replacement calculation or any other aspect of reporting to the Department of Treasury is independently reviewed to ensure the data u...

REPORTING State of West Virginia (WV) Assistance Listing Number 21.027 Going forward, WV will ensure that all data requested for calculations related to the revenue replacement calculation or any other aspect of reporting to the Department of Treasury is independently reviewed to ensure the data used is aligned with the parameters needed for reporting (e.g. all transactions fall within the proper dates, appropriate accounts and cost categories are included, etc.) prior to use for such calculations. Analytical procedures will be used to compare data used to other financial reports to ensure reasonableness.

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Finding 46226 (2022-009)

Material Weakness 2022

State of West Virginia

WV

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

SPECIAL TESTS AND PROVISION ? UI PROGRAM INTEGRITY - OVERPAYMENTS Workforce West Virginia (WWV) Assistance Listing Number 17.225, COVID-19 17.225 WWV will provide training to all Unemployment Insurance claim staff by March 2023 and review procedures related to the establishment of overpayments.

View Audit 40967 Questioned Costs: $1

Finding 46225 (2022-008)

Material Weakness 2022

State of West Virginia

WV

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

INTERNAL CONTROLS OVER INFORMATION TECHNOLOGY Workforce West Virginia (WWV) Assistance Listing Number 17.225, COVID-19 17.225 As of November 2022, WWV began and will continue to develop the processes for periodic review of user accounts for ABPS, UC Tax, and wvOASIS. Processes will include documen...

INTERNAL CONTROLS OVER INFORMATION TECHNOLOGY Workforce West Virginia (WWV) Assistance Listing Number 17.225, COVID-19 17.225 As of November 2022, WWV began and will continue to develop the processes for periodic review of user accounts for ABPS, UC Tax, and wvOASIS. Processes will include documenting termination of employees timely to the West Virginia Office of Technology (WVOT) to remove network access or within the organization to remove access to IT systems at the time of exit. WVOT will be adding features to Ivanti (WVOT service portal) so that WWV may download account management activity for validation, tracking, and review. WWV participates in Disaster Recovery operations when the WVOT holds them. Since WWV is covered by WVOT, WWV cannot reasonably procure a separate process for disaster recovery testing without the assistance and involvement of WVOT.

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Finding 46221 (2022-005)

Material Weakness 2022

State of West Virginia

WV

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

Community Development Block Grant Program (CDBG) Assistance Listing Number 14.228, COVID-19 14.228 Since the COVID pandemic occurred, the West Virginia Community Advance and Development office (CAD) experienced a high personnel turnover rate. As a result, CAD experienced a delay in implementing th...

Community Development Block Grant Program (CDBG) Assistance Listing Number 14.228, COVID-19 14.228 Since the COVID pandemic occurred, the West Virginia Community Advance and Development office (CAD) experienced a high personnel turnover rate. As a result, CAD experienced a delay in implementing the corrective action plan related to this finding. During the last 30 days, CAD has completed Federal Funding Accountability and Transparency Act (FFATA) training and has designated the personnel to the FFATA reporting process. Additionally, CAD has developed a checklist related to these grant awards which includes the FFATA system entry submission. These policies and procedures were implemented February 1, 2023.

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Finding 46216 (2022-004)

Material Weakness 2022

State of West Virginia

WV

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Department of Education (DOE) Assistance Listing Number 10.553, 10.555, 10.556, 10.559, 10.582 Program Management will implement policies and procedures to ensure Transparency Act reporting is conducted with proper reviews and timely submissions. In order to comply with the Federal Funding Account...

Department of Education (DOE) Assistance Listing Number 10.553, 10.555, 10.556, 10.559, 10.582 Program Management will implement policies and procedures to ensure Transparency Act reporting is conducted with proper reviews and timely submissions. In order to comply with the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act), as amended by Section 6202(a) of the Government Funding Transparency Act of 2008 (Pub. L. No. 111-252), that relate to sub-award reporting, DOE is working with the Child Nutrition Claiming Software vendor to create a report that will be run on the first of each month. Staff from the Office of Internal Operations and Office of Child Nutrition will be assigned to generate, enter, and submit data as required by the Transparency Act. To meet the timelines for reporting as established by the Transparency Act, the report will pull all activity for the prior month including all original reimbursement claims, as well as amendments that occur in that month to reimbursement claims that were previously reported. Prior to submission of the data, a report of its contents will be reviewed and approved by either the Child Nutrition Program Director or the Director of Internal Operations. Once the data is approved, it will be submitted. The timeline for development and initiation of this reporting process (barring any unforeseen system limitations) is tentatively set for July 1, 2023.

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Finding 46209 (2022-003)

None 2022

State of West Virginia

WV

Questioned Costs Eligibility Internal Control / Segregation of Duties

Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561 The DHHR Bureau for Family Assistance (the Bureau) analyzed the condition that led to this finding. The emergency supplement in question was paid on the initial month of SNAP issuance. However...

Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561 The DHHR Bureau for Family Assistance (the Bureau) analyzed the condition that led to this finding. The emergency supplement in question was paid on the initial month of SNAP issuance. However, these supplements were not to be based on the initial or prorated months of SNAP benefits. Per the U.S. Department of Agriculture, Food and Nutrition Service (FNS), emergency supplements were not to be initiated until the second month of SNAP issuance (i.e., the month following active SNAP approval). The emergency supplement allotments will end February 28, 2023. If the FNS instructs the Bureau to issue emergency supplement allotments for the SNAP Program beyond February 28, 2023, the Bureau will develop a blackboard course with video to ensure that all workers are trained on the procedures and policy. The blackboard platform has the capability to track who has completed the training which will ensure supervisors can determine who has or has not completed the required training.

View Audit 40967

Finding 46205 (2022-044)

Significant Deficiency 2022

State of West Virginia

WV

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

INTERNAL CONTROL ? PAYROLL Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, 93.658, 10.557 For the condition whereby a timecard for the WIC program was not approved by a manager in the automated payroll system, the DHHR Office of Human Resources Management (OHRM) r...

INTERNAL CONTROL ? PAYROLL Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, 93.658, 10.557 For the condition whereby a timecard for the WIC program was not approved by a manager in the automated payroll system, the DHHR Office of Human Resources Management (OHRM) received confirmation from the manager that the timecard was accurate. However, the confirmation was not obtained until after the state?s independent auditors inquired about the timecard. To enhance the controls and improve the documentation surrounding timecard approvals in general, the OHRM has instructed their payroll processors to use a log to note any issues with timecards prior to signing off on the timecards within the automated payroll system. The log will be shared with timekeepers and managers in the field (i.e., the various DHHR bureaus and offices throughout the state). The timekeepers and managers in the field will be required to note resolution of the issues directly on the log. If there are any unresolved issues remaining after signing off on the timecard in the system, the issues will be documented along with the manager?s actions. The ultimate goal is to obtain management approval for every timecard, whether such approval is documented directly within the automated payroll system prior to sign-off or documented outside of the system after sign-off. As is always the case, if adjustments to a timecard are necessary after the sign-off process, the OHRM will utilize their ?OHRM-36 Kronos Time & Leave Correction" form. When deemed necessary, the log and any related documentation will be shared with the state?s independent auditors during fieldwork for the West Virginia Single Audit. The anticipated date for completion of the log and the procedures related thereto is February 10, 2023. For the condition whereby the payroll system was unavailable due to a ransomware attack, the OHRM switched to a manual timekeeping system immediately after the attack and developed processes and controls related thereto. However, as the state?s independent auditors indicated, the OHRM did not maintain adequate documentation related to the controls and the precision of the controls in all instances. Accordingly, the OHRM is working on a contingency plan to document the steps to take in the event of another ransomware attack or any other incident that causes the automated payroll system to be unavailable. The anticipated date for completion is March 31, 2023.

View Audit 40967

Finding 46204 (2022-001)

Material Weakness 2022

State of West Virginia

WV

Allowable Costs / Cost Principles Eligibility Questioned Costs § 200.303

DHHR INFORMATION SYSTEM AND RELATED BUSINESS PROCESS CONTROLS Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561, 10.542, 93.558, COVID-19 93.558, 93.568, COVID-19 93.568, 93.575, 93.596, COVID-19 93.575, 93.658, 93.659, 93.767, 93.775, 93.777, ...

DHHR INFORMATION SYSTEM AND RELATED BUSINESS PROCESS CONTROLS Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561, 10.542, 93.558, COVID-19 93.558, 93.568, COVID-19 93.568, 93.575, 93.596, COVID-19 93.575, 93.658, 93.659, 93.767, 93.775, 93.777, COVID-19 93.777, 93.778, COVID-19 93.778, ARRA 93.778 Enhancing the Quality Control process (by adding other programs to the overall scope and expanding the populations for sampling to include payments that have case data that is initiated and approved by the same person as well as case data that is entered by one person without another level of approval) would prove costly for the DHHR due to the additional staff throughout the DHHR that would be required to accomplish such a task. Although enhancing the Quality Control process is still a possibility, upon further discussions within the DHHR, it was determined that prior to considering such an enhancement, the Bureau for Social Services, Bureau for Family Assistance, and other DHHR units should work together to perform the following: outline the existing internal controls over payments by payment type or program, determine the number of payments per month whereby one employee initiates and approves a payment (in relation to the population of all payments) and conclude on the risk of those payments being improper. Management can then identify areas of focus to conclude on the adequacy of the internal controls and make revisions to policies and procedures, if necessary. In short, although there are existing controls in place, the controls have not been documented and communicated to the State?s independent auditors in an effective manner.

View Audit 40967

Finding 46195 (2022-001)

Material Weakness 2022

Chehalis School District No. 302

WA

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

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Chehalis, WA 98532 360-807-7207 Corrective actio...

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Chehalis, WA 98532 360-807-7207 Corrective action the auditee plans to take in response to the finding: It is highly unusual for the district to utilize federal funds for construction projects; the Covid-19 Education Stabilization Funds were an anomaly. The District?s Director of Business and Operations was unaware that prevailing wage clauses are required to be included in all public works contracts over $2,000 that are paid with federal funds. She was aware that prevailing wages need to be paid. The audit finding does not dispute that prevailing wages were paid appropriately, just that the clauses were not included in the contracts. To be very clear, this finding is for not having required language in contracts. The District is now aware that inclusion of the clauses is a compliance requirement. Going forward, it is unlikely that federal funds will be used for construction projects; however, when federal funds are utilized for construction projects, the District will either include the required prevailing wage rate clauses in its contracts or will obtain a separate signed clause with the required prevailing wage rate information. Anticipated date to complete the corrective action: Immediately

View Audit 40903

Finding 46194 (2022-002)

Material Weakness 2022

Chehalis School District No. 302

WA

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

Finding ref number: 2022-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Cheh...

Finding ref number: 2022-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Chehalis, WA 98532 360-807-7207 Corrective action the auditee plans to take in response to the finding: The Chehalis School District does not concur with the finding or the questioned costs. The State Auditor?s Office (SAO) reviewed various types of documentation and did not accept documentation presented by the District to reduce or eliminate questioned costs. The standard of documentation required by SAO to satisfy ?unmet need? would have been hard to meet even if the District hadn?t been in the midst of a pandemic. The District has internal controls over asset inventory and provided equipment only to students and staff with unmet needs, and all costs were allowable, reasonable and necessary. We continue to communicate with other agencies with the ultimate goal of helping the Federal Communications Commission (FCC) understand that they should not seek any recovery of funds resulting from ?documentation? issues considering the massive public health response, deployment logistics, vague federal guidance, and the effective return to in-person learning. Along with countless other districts across the State of Washington, we look forward to working with the FCC to resolve this finding. We appreciate the guidance that was provided by the FCC, as noted below. Guidance from the FCC Devices for remote learning could also be used at school. During the pandemic in Washington State we experienced times when classrooms, schools and or districts were closed by health department and state regulations because of outbreaks. Districts had to be prepared to support remote learning each day with constantly changing guidance on who was allowed to be in person. The following guidance from the Federal Communications Commission, titled ?Emergency Connectivity Fund Common Misconceptions?, ?Misconception #2: If schools have returned to in-class instruction for the upcoming school year, they are not eligible to participate. Answer: This is false. Equipment and services provided to students or school staff who would otherwise lack sufficient access to connected devices, and/or broadband internet access connection while off campus are eligible for Emergency Connectivity Fund Support.? From the Federal Communications Commission Order FCC-CIRC21-93-043021, question 77: ?We think schools are in the best position to determine whether their students and staff have devices and broadband services sufficient to meet their remote learning needs, and we recognize that they are making such decisions in the midst of a pandemic. We, therefore, will not impose any specific metrics or process requirements on those determinations.? And from question 53: ??we are sensitive to the need to provide some flexibility during this uncertain time. If those connected devices were purchased for the purpose of providing students?with devices for off-campus use consistent with the rules we adopt today, we will not prohibit such on-campus use.? Corrective action the auditee plans to take in response to the finding: The Chehalis School District does not concur with the finding or the questioned costs. The State Auditor?s Office (SAO) reviewed various types of documentation and did not accept documentation presented by the District to reduce or eliminate questioned costs. The standard of documentation required by SAO to satisfy ?unmet need? would have been hard to meet even if the District hadn?t been in the midst of a pandemic. The District has internal controls over asset inventory and provided equipment only to students and staff with unmet needs, and all costs were allowable, reasonable and necessary. We continue to communicate with other agencies with the ultimate goal of helping the Federal Communications Commission (FCC) understand that they should not seek any recovery of funds resulting from ?documentation? issues considering the massive public health response, deployment logistics, vague federal guidance, and the effective return to in-person learning. Along with countless other districts across the State of Washington, we look forward to working with the FCC to resolve this finding. We appreciate the guidance that was provided by the FCC, as noted below. Guidance from the FCC Devices for remote learning could also be used at school. During the pandemic in Washington State we experienced times when classrooms, schools and or districts were closed by health department and state regulations because of outbreaks. Districts had to be prepared to support remote learning each day with constantly changing guidance on who was allowed to be in person. The following guidance from the Federal Communications Commission, titled ?Emergency Connectivity Fund Common Misconceptions?, ?Misconception #2: If schools have returned to in-class instruction for the upcoming school year, they are not eligible to participate. Answer: This is false. Equipment and services provided to students or school staff who would otherwise lack sufficient access to connected devices, and/or broadband internet access connection while off campus are eligible for Emergency Connectivity Fund Support.? From the Federal Communications Commission Order FCC-CIRC21-93-043021, question 77: ?We think schools are in the best position to determine whether their students and staff have devices and broadband services sufficient to meet their remote learning needs, and we recognize that they are making such decisions in the midst of a pandemic. We, therefore, will not impose any specific metrics or process requirements on those determinations.? And from question 53: ??we are sensitive to the need to provide some flexibility during this uncertain time. If those connected devices were purchased for the purpose of providing students?with devices for off-campus use consistent with the rules we adopt today, we will not prohibit such on-campus use.? Anticipated date to complete the corrective action: We will work with the FCC to resolve this issue according to their timeline.

View Audit 40903 Questioned Costs: $1

Finding 46193 (2022-001)

Material Weakness 2022

Louisiana Human Resources Dev. Institute

LA

Internal Control / Segregation of Duties

Management has noted this condition and has determined that the cost necessary to establish adequate segregation of duties is not justifiable at this time.

View Audit 40865

Finding 46191 (2022-001)

Significant Deficiency 2022

Town of Westport, Conencticut

CT

Internal Control / Segregation of Duties Questioned Costs Reporting

FINDING - FEDERAL AWARD PROGRAMS AUDIT United States Department of the Treasury 2022-001 COVID-19 American Rescue Plan Act Local Fiscal Recovery ? AL No. 21.027 Recommendation: We recommend that the Town implement a control for the Project and Expenditure Report to be reviewed by an individual ind...

FINDING - FEDERAL AWARD PROGRAMS AUDIT United States Department of the Treasury 2022-001 COVID-19 American Rescue Plan Act Local Fiscal Recovery ? AL No. 21.027 Recommendation: We recommend that the Town implement a control for the Project and Expenditure Report to be reviewed by an individual independent of the preparation process prior to submission to the Treasury. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with this finding. Management further notes that a two-step review process has been implemented where the Controller will review the documents sign-off before the Finance Directors submits them through the State portal. The of the contact person responsible for corrective action: Sheila Carey Planned completion date for corrective action plan: March 30, 2023.

View Audit 40828

Finding 46184 (2022-001)

Material Weakness 2022

Caromont Health, Inc.

NC

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Finding 2022-001 Contact Person: Shari Reese Completion Date: March 13, 2023 Managements Response: Reporting Period 1: During Reporting Period 1, several subsidiaries of CaroMont Health, Inc. (?Parent?) received general distributions from the CARES Act Provider Relief Fund (?PRF?). Management ...

Finding 2022-001 Contact Person: Shari Reese Completion Date: March 13, 2023 Managements Response: Reporting Period 1: During Reporting Period 1, several subsidiaries of CaroMont Health, Inc. (?Parent?) received general distributions from the CARES Act Provider Relief Fund (?PRF?). Management reported all the general distributions received by the subsidiaries under the Parent entity in the portal, including the general distributions received by CaroMont Regional Medical Center (?Hospital?). Management listed the TINS of the subsidiaries, including the Hospital, in the Subsidiary Data section in the Parent?s portal. Management reported lost revenues utilizing option i, 2019 Actual Revenues, for the subsidiaries in the Parent?s portal. Reporting Period 2: During Reporting Period 2, the Hospital received both general and a targeted distributions (High Impact Area) from the CARES Act PRF. Management was unsure how to report so it contacted the HRSA Provider Support Line. HRSA opened case #00025470 and on January 18, 2022, Management had a phone conference with a representative of HRSA to discuss Period 2 reporting. HRSA advised management to report as follows: ? Hospital ? report the targeted distribution. Only report revenue, expenses, and data for the Hospital. ? Parent ? report general distributions. Don?t change any numbers from Period 1. Report revenue, expenses, and data for all subsidiary TINS listed in the portal. Management specifically remembers explaining to the HRSA representative that this approach would result in double counting of Total Unused Lost Revenues because Hospital revenues would be reported in both portals. The HRSA representative said that would be okay because Management answered YES to ?Is the parent entity reporting on your General Distribution payments?? in the Hospital portal, because the Hospital?s TIN is listed in the Subsidiary Information section in the Parent?s portal, and because the Parent?s TIN is listed in the Subsidiary Questionnaire section in the Hospital?s portal. Management documented these instructions in their notes made during the call. Management also specifically remembers asking the HRSA representative if the Hospital revenue should be removed from the prior quarters in the Parent portal when reporting Period 2 to which the representative replied, ?don?t change any numbers?. Management documented these instructions in their notes made during the call. Management filed the Period 2 reports for the Parent and the Hospital in accordance with HRSA?s instructions received during this phone conference. Management reported lost revenues under option i, 2019 Actual Revenues, for the listed subsidiaries in the Parent portal and for the Hospital in the Hospital portal. However, since Management was concerned this approach would result in double counting of unused lost revenues, they created a reconciliation spreadsheet on February 1, 2022. This spreadsheet documented unused lost revenues from the PRF Financial Reporting Summary Reporting pages in the Parent and Hospital portals for Period 1 and Period 2 and calculated the correct total unused lost revenues when the reports were combined and the double counting was eliminated. Management?s intent was to update this reconciliation during Period 4 reporting to ensure the remaining unused lost revenues in both the Parent and Hospital portals exceeded the combined reconciled lost revenue ? thereby ensuring there would be no double counting of lost revenues after all PRF reporting was completed. Reporting Period 4: During Report Period 4, several subsidiaries of the Parent received general distributions from the CARES Act PRF and targeted distributions from the American Rescue Plan (?ARP?). By the time the Portal Reporting opened for Period 4, CaroMont?s auditors were conducting the Single Audit for the year ended June 30, 2022, and reached out to Management to discuss their concerns about potential double counting of lost revenues in the Period 2 portal reporting. Management explained their process for reporting Period 2 and shared with the auditors their reconciliation spreadsheet that was created on February 1, 2022. The auditors had also performed a reconciliation that resulted in the same outcome. The auditors and management subsequently had several discussions on the different alternatives available to correct the Period 2 overstatement. Management evaluated the alternatives and ultimately decided to change its calculation of Lost Revenues in the Parent portal for Period 4 from option i, 2019 Actual Revenue, to option iii, Alternative Method of Calculating Lost Revenues Attributable to COVID-19. However, management continued to report lost revenues in the Hospital portal for Period 4 utilizing option i, 2019 Actual Revenue, as it had in Period 2. Management created another reconciliation spreadsheet on February 23, 2023 that demonstrated the Hospital revenue was excluded from the Parent?s lost revenue calculations in Period 4. This spreadsheet was uploaded as supporting documentation for option iii in the Parent?s portal. By changing from option i to option iii for lost revenues in the Parent portal for Period 4, management corrected the overstatement of lost revenues identified in the Audit of Federal Awards Performed in Accordance with U.S. Office of Management and Budget Uniform Guidance for the year ended June 30, 2022.

View Audit 41344

Finding 46182 (2022-002)

Significant Deficiency 2022

Cle Elum-Roslyn School District No. 404

WA

Subrecipient Monitoring Questioned Costs Internal Control / Segregation of Duties

The District concurs and will review current year?s indirect rates for ESSER reimbursements.

View Audit 41236 Questioned Costs: $1

Finding 46168 (2022-001)

Significant Deficiency 2022

Community Medical Centers, Inc.

CA

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties

Name of Contact Person(s) Responsible for Corrective Action: Jaime Allen, Chief Financial Officer Training: Retrain staff on sliding fee policy procedures to ensure (1) income is properly verified, adequately documented and retained and (2) the sliding fee discount is properly determined and applied...

Name of Contact Person(s) Responsible for Corrective Action: Jaime Allen, Chief Financial Officer Training: Retrain staff on sliding fee policy procedures to ensure (1) income is properly verified, adequately documented and retained and (2) the sliding fee discount is properly determined and applied. All new Front Office staff will receive sliding fee program training as part of their 4-day front office training during onboarding. By Feb 28, 2022, the Front Office Trainer will review documentation requirements around sliding fee scale for patients, including checking applications for completion and making sure the sliding fee applied is being correctly calculated by all Front Office Leads, Supervisors and Center Managers. By Mar 2, 2022, the Front Office Trainer will help create a front office compliance checklist to review front office procedures around documentation, insurance, sliding fees and other programs. Sliding Fee Annual Update: The Revenue Cycle Director will notify the Applications Team and Front Office trainer each year when the sliding fee scale has been updated. The Applications Team will update the UDS table and map to the calculator in the EHR. The Front Officer trainer will review sliding fee updates on an annual basis update trainings with front office staff and within thirty days of notification of any sliding fee policy revisions. Internal Audit: An additional level of review will be added to the process to ensure program compliance. The Revenue Cycle Director will create and document a sliding fee scale internal audit process that will be performed monthly. When the audit is performed, findings will be reported to the following: General Counsel & Compliance Officer, Chief Financial Officer, Chief Operating Officer, Front Officer Trainer, Center Manager, and lead/supervisors. Front Office Trainers will work closely with Center Managers, Leads and Supervisors to ensure that ongoing compliance on sliding fees are met based on internal audit findings. Refresher trainings to staff will be provided based on patterns determined by internal audit findings. This process was implemented on March 2, 2022. Anticipated Completion Date: March 2, 2022

View Audit 41173

Finding 46163 (2022-002)

Significant Deficiency 2022

Shepherd Public School District

MI

Questioned Costs Cash Management Reporting

Finding 2022-002 ? REPORTING Type: Significant Deficiency in Internal Control! Noncompliance ? Reporting Program: Child Nutrition Cluster (ALN 10.553, 10.555 and 10.559) Condition: Meals claimed were not supported by count sheets for lunch for one of the two months meals were tested. Criteria: The D...

Finding 2022-002 ? REPORTING Type: Significant Deficiency in Internal Control! Noncompliance ? Reporting Program: Child Nutrition Cluster (ALN 10.553, 10.555 and 10.559) Condition: Meals claimed were not supported by count sheets for lunch for one of the two months meals were tested. Criteria: The District is required to claim meals served, by category, based on reports provided from individual meal serve counts. Cause: This condition was caused by an insufficient internal control process for comparison of supporting documentation of meal counts to meal claims. Effect: Based on a comparison of meals claimed to reports provided from individual meal serve counts, the District has underclaimed reimbursement for the year by an immaterial amount. Questioned Costs: None. Recommendation: We recommend that the District review their process of meal claims and make necessary changes to ensure that all meals claimed, by category, agree to supporting documentation. Corrective Action Plan: Shepherd Public Schools Food Service Department will implement internal control review process to ensure that individual meal serve counts match identically the meals claimed by reviewing original count sheets at the time of certification of meal claims. Either the food service director or assigned designee will verify counts at the end of each month. This internal control review process will begin effective with the October 2022 claims report.

View Audit 41016

Corrective Action Plans

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