Corrective Action Plans

Finding 496931 (2023-001)

Material Weakness 2023

GA

Questioned Costs Material Weakness Reporting

Hospital Authority of Liberty County (A Component Unit of Liberty County, Georgia) respectfully submits the following corrective action plan for the year ended November 30, 2023. The finding from the November 30, 2023 Schedule of Findings and Questioned Costs is discussed below. The finding is numbe...

Hospital Authority of Liberty County (A Component Unit of Liberty County, Georgia) respectfully submits the following corrective action plan for the year ended November 30, 2023. The finding from the November 30, 2023 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDING Material Weakness - Noncompliance (2023-001) Recommendation: The Authority should continue to improve its understanding of the reporting requirements as specified in the applicable loan document and create a process to ensure all USDA requirements are met. Planned Corrective Action: The Authority has elected to pay off the outstanding balance of the USDA loan. Derek Rozier Chief Financial Officer

View Audit 319668 Questioned Costs: $1

Finding 496850 (2023-004)

Significant Deficiency 2023

The Food Trust

PA

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Significant Deficiency

There was a lack of documentation for the purchase of program supplies in the amount of $200 charged to federal programs. Recommendation: We recommend The Food Trust review its processes to ensure that all supporting documentation is maintained for federal purchases. Explanation of disagreement w...

There was a lack of documentation for the purchase of program supplies in the amount of $200 charged to federal programs. Recommendation: We recommend The Food Trust review its processes to ensure that all supporting documentation is maintained for federal purchases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will complete a review of its documentation by December 2024. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed by December 31, 2024. If the oversight agency has questions regarding this plan, please call Regine Metellus, Vice President of Finance at 215-575-0444 ext. 163.

View Audit 319570

Finding 496819 (2023-001)

Material Weakness 2023

Mark Twain Association for Mental Health Inc.

MO

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Cash Management § 200.302 § 200.430

September 9, 2024 Re: SAMHSA Notice of Award for 6H79SM083161-01M003 MTBH submitted our budget based on anticipated salary costs for new hires, which we believe stayed at or below our actual costs. We made available all necessary documentation requested from payroll, grant-related expenses, grant r...

September 9, 2024 Re: SAMHSA Notice of Award for 6H79SM083161-01M003 MTBH submitted our budget based on anticipated salary costs for new hires, which we believe stayed at or below our actual costs. We made available all necessary documentation requested from payroll, grant-related expenses, grant reports and timekeeping records to Wade Stables P.C for review. We did not have the grant in our financial software as we were beginning a migration to new software during the early stages of the grant; therefore, we tracked that grant on an excel spreadsheet that annually was provided to our auditors. Most of the staff assigned to the grant were full-time staff, so time allocation was easily tracked. For the few staff that were part-time we had designated codes in our Electronic Medical Record to identify work done on behalf of the grant. In response to Finding 2023-001- B Allowable Costs, we agree with the Statement of Cause citing the exponential growth of the organization regarding preparedness for a first-time grant award of this size being our largest challenge. Initially we were informed we had not received the grant then, due to additional COVID funding, we were invited to participate in the grant with a very short turnaround to finalize budgets and hire staff. Our salaries are consistent with the positions designated in the grant and in a few cases our staff salaries exceeded the allowable costs; therefore, those allowable costs were used to calculate the drawdown. MTBH did not have an established de minimis rate; therefore, we used the 10% designated rate associated with the grant. The interactive Budget Narrative Form template, required per SAMHSA guidelines, had 10% built into the template. If afforded future opportunities to secure a SAMSHA grant, we would be better positioned to execute the financial management in our SAGE software to segregate costs for the purpose of tracking the expenditures associated agency grant operations. Currently all agency expenditures have transferred into SAGE by our Vice President of Finance, Jenny Haught MBA, which would also be the Responsible Official to fiscally manage future grants. Respectfully, Angela Caraway, VP of Clinical Operations

View Audit 319554

Finding 496817 (2023-004)

Significant Deficiency 2023

Texas Biomedical Research Institute

TX

Reporting Matching / Level of Effort / Earmarking § 200.303

Texas Biomed agrees with late progress report submissions, though did obtain a letter from the EDA Project Manager confirming the EDA reviewed and accepted all required 2023 progress reports and that Texas Biomed was compliant with all reporting requirements in 2023. The late progress report submi...

Texas Biomed agrees with late progress report submissions, though did obtain a letter from the EDA Project Manager confirming the EDA reviewed and accepted all required 2023 progress reports and that Texas Biomed was compliant with all reporting requirements in 2023. The late progress report submissions were a result of the consecutive departure of two senior Sponsored Program Administrators in early 2023 that had been assigned responsibility of submitting the EDA project deliverables. Their consecutive departure left a gap in oversight of the deliverable submission due to the manual tracking of such. As of June 2024, the EDA has implemented an online award management portal, EDGE, that sends automated notices/reminders in advance of reporting deliverable due dates, as well as past due notices for unsubmitted deliverables. Multiple Texas Biomed administrators have been assigned points of contact and recipients of these notices from EDGE. The points of contact include, Director, Assistant Director, and a post-award administrator in Sponsored Programs Administration (SPA), in addition to the Controller in the department of Finance. Additionally, the post-award administrator assigned to the EDA project(s) will add an Outlook calendar reminder/due date for deliverables that will include the Project Director, Assistant Director (SPA) and themselves to provide ample notice for preparation and submission of deliverables in a timely manner. Responsible Parties: Eduardo Meza, Director, Sponsored Programs Administration; Pamela Futch, Assistant Director, Post-Award, Sponsored Programs Administration Completion Date: September 30, 2024

View Audit 319544

Finding 496816 (2023-003)

Material Weakness 2023

Texas Biomedical Research Institute

TX

Matching / Level of Effort / Earmarking Reporting § 200.303 § 200.326

The award subject to this finding was a novel award for Texas Biomed and, therefore, controls relative to the wage rate requirements were not in place. Texas Biomed relied on the general contractor awarded the construction project to facilitate compliance with the special tests and provisions; howe...

The award subject to this finding was a novel award for Texas Biomed and, therefore, controls relative to the wage rate requirements were not in place. Texas Biomed relied on the general contractor awarded the construction project to facilitate compliance with the special tests and provisions; however, failed to validate that certified payrolls were provided as required. Texas Biomed has since implemented enhanced procedures and controls. Purchasing will ensure contracts subject to Davis Bacon Act requirements will clearly outline the responsibilities of the general contractor, as well as requiring flow down to subcontractors. For the Animal Care Complex project partially funded by the EDA award, Purchasing will request certified payrolls dating back to the start of the project from the contractor and subcontractors. Certified Payrolls will only be accepted via DOL form WH347. Texas Biomed has engaged an external project management firm to support extensive new construction underway or soon to commence on Texas Biomed’s campus. The consultant, as part of the scope of their engagement, will serve as the first reviewer of invoices and pay apps, and payment requests will not progress without their approval. The review will include verification of inclusion of necessary certified payrolls. Documentation will be saved in a shared Dropbox folder, where Texas Biomed Facilities personnel will review and sign off on the cover letter from the consultant, verifying Texas Biomed’s review of the necessary certified payrolls at that time. When the pay app is entered by Texas Biomed Accounts Payable in the automated system for invoice payment, the payment request will automatically route to a designated Texas Biomed Facilities staff member. This second staff member will provide a final review of the certified payrolls as a condition for approving the invoice for payment. Both Facilities staff members will have access to the certified payrolls and approval at each step will signify the necessary documentation has been received. If there is a lack of proper documentation, Facilities personnel will alert Accounts Payable of the reason for delay. Facilities personnel will follow up with the project management consultant and contractor to request additional backup when necessary. Responsible Parties: Amber Garcia, Facilities Operations Coordinator; Mike Merz, Principal Engineer; Patricia Thompson, Assistant Director, Materials Management Completion Date: December 31, 2024

View Audit 319544

Finding 496765 (2023-002)

Material Weakness 2023

Fairview Health Services

MN

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

Finding 2023-002 Federal Grantor: United States Department of the Homeland Security Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – August 31, 2024 Management agrees with the finding. In May 2023, the COVID-19 emer...

Finding 2023-002 Federal Grantor: United States Department of the Homeland Security Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – August 31, 2024 Management agrees with the finding. In May 2023, the COVID-19 emergency was ended and therefore remediation of internal controls specific to allowability of costs for the FEMA program are no longer applicable. However, remediation steps were taken to improve documentation of review of internal controls over all federal expenditures, not limited to the FEMA program. Remediation: Fairview revised its internal control processes to improve the retention and documentation of the review and approval of inputs to the calculation of federal expenditures, as well as ensure that the review is precise enough to challenge the appropriateness of the methodology utilized.

View Audit 319532

Finding 496764 (2023-001)

Material Weakness 2023

Fairview Health Services

MN

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

Finding 2023-001 Federal Grantor: United States Department of the Homeland Security Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – August 31, 2024 Management agrees with the finding. In May 2023, the COVID-19 emer...

Finding 2023-001 Federal Grantor: United States Department of the Homeland Security Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – August 31, 2024 Management agrees with the finding. In May 2023, the COVID-19 emergency was ended and therefore remediation of internal controls specific to allowability of costs for the FEMA program are no longer applicable. However, remediation steps were taken to improve documentation of review of internal controls over all federal expenditures, not limited to the FEMA program. Remediation: Fairview revised its internal control processes to improve the retention and documentation of the review and approval of inputs to the calculation of federal expenditures.

View Audit 319532

Finding 496747 (2023-001)

Significant Deficiency 2023

U.s. Dream Academy, Inc.

MD

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.430

U.S. Dream Academy, Inc. submits the following corrective action plan for the year ended December 31, 2023. The finding from the schedule of findings and questioned costs dated August 23, 2024 is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDI...

U.S. Dream Academy, Inc. submits the following corrective action plan for the year ended December 31, 2023. The finding from the schedule of findings and questioned costs dated August 23, 2024 is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-001 Internal Controls and Compliance over Allowable Costs and Activities - Payroll (Significant Deficiency) Recommendation: We recommend the Academy establish policies and procedures to reconcile the percentage of hours charged on time slips to the budget estimates used to bill the Federal grantor. This should be in conjunction with quarterly billings (or other determined regular interval), at fiscal year end, and at the end of the grant year (if different from the Academy’s fiscal year). Corrective Action: On November 20, 2023, U.S. Dream Academy entered into a contractual agreement with ADP Comprehensive Services to move electronic time cards from Attendance on Demand to ADP Time & Attendance. This change in software will allow program and grant allocations made by employees on time cards to be directly imported into payroll processing as is, eliminating the need to manually enter the summation of all hours worked over the pay period and manually breaking down the allocation for entry into the general ledger. The Time & Attendance software went “live” with the pay period ending May 18, 2024. Each pay period, the Financial Controller will reconcile actual time worked (as per time card) against budgeted salary allocations. The Chief Financial Officer will review these reconciliations prior to grant reporting and at year end closings. Responsible Parties: Phylicia Buie, CFO and Chris Moore, Financial Controller Date Corrected: August 23, 2024 If there are any questions regarding this plan, please contact Phylicia Buie pbuie@usdreamacademy.org or Christine Moore at cmoore@usdreamadacemy.org .

View Audit 319505 Questioned Costs: $1

Finding 496677 (2023-003)

None 2023

Santa Cruz Community Cu

CA

Eligibility Reporting Material Weakness

Views of Responsible Officials Responsible/Contact Official Paul Barenfus, CLO, and Sylvia Sanchez, CFO Management Response The ERP Grant is a very different grant from previous grants received by the Credit Union. Although management followed the instructions provided on the CDFI website, it was no...

Views of Responsible Officials Responsible/Contact Official Paul Barenfus, CLO, and Sylvia Sanchez, CFO Management Response The ERP Grant is a very different grant from previous grants received by the Credit Union. Although management followed the instructions provided on the CDFI website, it was not clear that running the loan through the ERP track for eligibility was only one of several steps. After auditors noted that 4 loans were ineligible, management searched the website to find the second track that the loans had to be qualified through, the Majority-Minority Census. The team has not had to qualify loans like this in the past, and the additional third step for qualification was not understood. Management has since replaced the unqualified loans on the 2023 SEFA with eligible loans. Documented procedures for the ERP Grant have been completed and are being followed. Anticipated Completion Date This item is complete.

View Audit 319492

Finding 496664 (2023-003)

Material Weakness 2023

Fort Frye Local School District

OH

Subrecipient Monitoring Cash Management Material Weakness § 200.302 § 200.303

Finding Number: 2023-003 Planned Corrective Action: The accounts payable clerk will double check all claims submitted to the state for accuracy. Anticipated Completion Date: 08/30/2024 Responsible Contact Person: Stacy Bolden

View Audit 319478

Finding 496661 (2023-001)

Material Weakness 2023

Annex Teen Clinic, Inc.

MN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.400

Recommendation: We recommend the Annex Teen Clinic, Inc. document the authorization of expenditures charged to federal awards and ensure documentation is available to support such expenditures. Planned Action: We have implement a new Accounts Payable Automation Sofware called Continia, which will ma...

Recommendation: We recommend the Annex Teen Clinic, Inc. document the authorization of expenditures charged to federal awards and ensure documentation is available to support such expenditures. Planned Action: We have implement a new Accounts Payable Automation Sofware called Continia, which will make reimbursement, invoicing, and credit card submission processes more efficient and advanced. With this new software, we will be able to streamline our accounts payable processes and save a significant amount of time. Continia will allow everyone to submit their expenses and mileage trips on the Continia Expense Portal. It will also automate the approval process.

View Audit 319477

Finding 496612 (2023-002)

Significant Deficiency 2023

True Access Capital Corporation

DE

Reporting Matching / Level of Effort / Earmarking

Corrective Action Plan: TAC will create a comprehensive spreadsheet to consolidate all federal reporting deadlines. This spreadsheet will delineate the appropriate staff accountable for each report and facilitate efficient tracking of completion and submission dates. Responsible Person: Vandell Hamp...

Corrective Action Plan: TAC will create a comprehensive spreadsheet to consolidate all federal reporting deadlines. This spreadsheet will delineate the appropriate staff accountable for each report and facilitate efficient tracking of completion and submission dates. Responsible Person: Vandell Hampton, Jr., President & CEO Anticipated Completion Date: September 30, 2024

View Audit 319411

Finding 496611 (2023-005)

Significant Deficiency 2023

Hendry County Bocc

FL

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

The County will implement necessary internal controls to ensure that expenditures included as allowable costs are in compliance with the requirements of the program and the Uniform Guidance. Additionally, the County will ensure that relevant personnel are properly trained to perform procedures to ac...

The County will implement necessary internal controls to ensure that expenditures included as allowable costs are in compliance with the requirements of the program and the Uniform Guidance. Additionally, the County will ensure that relevant personnel are properly trained to perform procedures to accurately report expenditures.

View Audit 319410

Finding 496610 (2023-004)

Material Weakness 2023

Hendry County Bocc

FL

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

The County will implement necessary internal controls to ensure that expenditures included as allowable costs are in compliance with the requirements of the program and the Uniform Guidance. Additionally, the County will ensure that relevant personnel are properly trained to perform procedures to ac...

The County will implement necessary internal controls to ensure that expenditures included as allowable costs are in compliance with the requirements of the program and the Uniform Guidance. Additionally, the County will ensure that relevant personnel are properly trained to perform procedures to accurately report expenditures.

View Audit 319410

Finding 496481 (2023-003)

Significant Deficiency 2023

City of Warwick, Rhode Island

RI

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Special Education - Preschool Grants (IDEA Preschool) – Assistance Listing # 84.173 Recommendation: We recommend the Department develop and document internal controls to provide proper support and approval over the allocation of salaries. Explanation of disagreement with audit finding: There is no...

Special Education - Preschool Grants (IDEA Preschool) – Assistance Listing # 84.173 Recommendation: We recommend the Department develop and document internal controls to provide proper support and approval over the allocation of salaries. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Finance will routinely review salary allocations to IDEA and compare to grant budget. Adjustments to allocations should be documented with support. WPS is implementing a new financial reporting system that includes a grant reporting module – this will help resolve issues with internal controls related to grants moving forward. Name(s) of the contact person(s) responsible for corrective action: Brandon Bohl - Director of Finance Warwick Public Schools Planned completion date for corrective action plan: June 30, 2025

View Audit 319403

Finding 496471 (2023-002)

Significant Deficiency 2023

City of Warwick, Rhode Island

RI

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

Education Stabilization Fund – Assistance Listing # 84.425D Recommendation: We recommend the City reviews and enhances internal controls and procedures to ensure that all reports are prepared and reviewed for accuracy and supporting documentation maintained. Explanation of disagreement with audit ...

Education Stabilization Fund – Assistance Listing # 84.425D Recommendation: We recommend the City reviews and enhances internal controls and procedures to ensure that all reports are prepared and reviewed for accuracy and supporting documentation maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WPS is implementing a new financial reporting system that includes a grant reporting module – this will help resolve issues with internal controls related to grants moving forward. Name(s) of the contact person(s) responsible for corrective action: Brandon Bohl - Director of Finance Warwick Public Schools Planned completion date for corrective action plan: June 30, 2025

View Audit 319403

Finding 496458 (2023-004)

None 2023

Saint John's Program for Real Change

CA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

2023-004— REPORTING Jose Dominguez, Interim CEO, jdominguez@saintjohnsprogram.org Corrective Action Planned: Saint John's Program for Real. Change is dedicated to the meticulous implementation of a system for preserving financial records, supporting documents, statistical records, and all other non-...

2023-004— REPORTING Jose Dominguez, Interim CEO, jdominguez@saintjohnsprogram.org Corrective Action Planned: Saint John's Program for Real. Change is dedicated to the meticulous implementation of a system for preserving financial records, supporting documents, statistical records, and all other non-Federal entity records relevant to a Federal award. The electronic versions of these documents will be consistently stored in the Sharepoint cloud on a monthly basis for permanent retention. Furthermore, the organization will produce paper copies of these documents and securely maintain them in an archive accessible exclusively to authorized personnel. The paper copies will be systematically arranged by year and alphabetical order to facilitate efficient retrieval upon request by auditors or reviewing entities. A comprehensive schedule delineating the stipulated retention period for each document type will be generated in accordance with the pertinent Uniform Guidance record retention guidelines. In addition, all supporting documentation pertaining to a program funded by a Federal Grant, whether comprising an intake form or client information, will be stored in both digital and paper formats, and will be maintained in compliance with the record retention guidelines outlined in the Uniform Guidance. AlL records wilt undergo an annual review prior to filing to ensure the presence of all necessary documents and uniform adherence to regulatory requirements. Anticipated Completion Date: 8/30/2024

View Audit 319380

Finding 496454 (2023-003)

Material Weakness 2023

City of Greenwood, Wisconsin

WI

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

Finding 2023-003 Condition: Internal controls over federal grants should be in place to provide reasonable assurance that a misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state grants or have gra...

Finding 2023-003 Condition: Internal controls over federal grants should be in place to provide reasonable assurance that a misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state grants or have grant programs should have documented policies and procedures in place over grants and grant expenditures. Cause: The City does not have documented policies and procedures in place over grants and grant expenditures. Effect: Without documented policies and procedures, the internal control over federal grants is low, and the risk of misstatement in the schedule of federal awards is high. Auditor’s Recommendation: We recommend that the City adopt written policies and procedures over grants and grant expenditures. Management Response: The City will work with their auditor to develop and adopt written grant procedures that are in accordance with the Uniform Guidance. Contact Person: Kayla Schar Anticipated Completion: Ongoing

View Audit 319375

Finding 496444 (2023-002)

Significant Deficiency 2023

Del Norte Child Care Council

CA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.512

Management agrees that due to turnover in staff during 2022 and 2023, there were gaps in communication leading to the single audit not being completed and submitted to the Federal Audit Clearinghouse be the due date. As of the audit report date, the Council has engaged an outside accounting firm to ...

Management agrees that due to turnover in staff during 2022 and 2023, there were gaps in communication leading to the single audit not being completed and submitted to the Federal Audit Clearinghouse be the due date. As of the audit report date, the Council has engaged an outside accounting firm to provide financial oversight. Action: Develop procedures to ensure required single audits are completed and submitted to the Federal Audit Clearinghouse by the 9-month due date. Due Date: 8/1/24 Staff: Don Reynolds, contracted CFO Carrie Castillo, Executive Director, is the official responsible for implementing each corrective action plan.

View Audit 319367

Finding 496442 (2023-001)

Material Weakness 2023

Del Norte Child Care Council

CA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Management agrees that due to turnover in staff during 2022 and 2023, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being updated on a continuing basis as reimbursement requests were being to the California Department of Social Ser...

Management agrees that due to turnover in staff during 2022 and 2023, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being updated on a continuing basis as reimbursement requests were being to the California Department of Social Services. Management believes that all key accounting positions have since been filled by qualified personnel. A formal close process and reconciliation of all balance sheet accounts and indirect cost allocations each month will ensure reimbursement requests are complete and accurate. Process documentation is also being prepared to help personnel in the accounting department follow proper control procedures. Action: Develop and document process for drawdown calculation and year end reconciliation to accounting records. Due Date: 8/1/24 Staff: Don Reynolds, contracted CFO

View Audit 319367

Finding 496413 (2023-001)

Material Weakness 2023

Kosciusko County

IN

Internal Control / Segregation of Duties Cash Management Material Weakness § 200.302 § 200.303 § 200.328 § 200.329 § 200.344

FINDING 2023-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Kosciusko County Sheriff's Office applied for the Indiana Local Body Camera Grant (ILBC). The sheriff’s office was awarded this grant on January 1, 2023, with a grant cost amount o...

FINDING 2023-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Kosciusko County Sheriff's Office applied for the Indiana Local Body Camera Grant (ILBC). The sheriff’s office was awarded this grant on January 1, 2023, with a grant cost amount of up to $31,920. This grant is a reimbursable grant through the Indiana Department of Homeland Security. The period of performance was from January 1, 2023, to December 31, 2023. The Kosciusko County Sheriff's Office ordered body-worn cameras and equipment on April 26, 2023. The invoice for the cameras and the camera equipment was paid on July 14, 2023. The Kosciusko County Sheriff's Office then submitted a Reimbursement Claim Form on September 11, 2023. The Reimbursement Claim Form shows the Sheriff's Office incorrectly requested the full $31,920. They received $31,920 from the Indiana Department of Homeland Security on September 27, 2023. However, the county had only spent $9,581 of the grant money towards the body camera purchase. Therefore, there is a remaining balance in the fund of $22,339 as of December 31, 2023. Due to the period of performance, the county should have reimbursed the Indiana Department of Homeland Security $22,339. On May 9, 2023, the Sheriff's Office grant administrator submitted a Program Report for the ILBC grant. This report was filed without an implemented internal control or evidence of a review. The report was completed and submitted by the Sheriff's Office grant administrator. The report incorrectly indicated that all expenditures had been completed. As of the date of the submission, the county had not purchased the bodyworn cameras and all federal funds had not been expended. Contact Person Responsible for Corrective Action: Alyssa Schmucker Contact Phone Number and Email Address: 574-372-2325 aschmucker@kosciusko.in.gov View of Responsible Officials: We concur with the findings identified. Description of Corrective Action Plan: The Kosciusko Sheriff’s Office, grant coordinator will contact IDHS for instruction on how to return the $22,339.00 and prepare a claim to be processed by the Kosciusko County Auditor’s office. The grant balances are submitted each month by departments these are checked and confirmed by the Auditor’s Office this one was overlooked in the review process. The person who applied for the grant no longer works for the county. It is believed the new person handling the grants was not aware that this grant even existed. The Grant Administrator(s) will have someone sign off on the grant report submissions and forward all reports to the Auditor’s Office. Anticipated Completion Date: It is anticipated that this will be completed as soon as the information to return the funds is received from the state and the claim is submitted to the Auditor for payment. This claim will be paid as soon as it is received. On or before 12/31/2024.

View Audit 319325

Finding 496412 (2023-005)

Material Weakness 2023

Marshall County Fiscal Court

KY

Matching / Level of Effort / Earmarking § 200.303

This finding covers a fiscal year for which the first half concluded prior to Kevin Spraggs’ term as County Judge/Executive. Additionally, FY23, as well as the prior year FY22, audits were completed toward the end of FY24 – therefore any auditor recommendations and corrective actions would not be in...

This finding covers a fiscal year for which the first half concluded prior to Kevin Spraggs’ term as County Judge/Executive. Additionally, FY23, as well as the prior year FY22, audits were completed toward the end of FY24 – therefore any auditor recommendations and corrective actions would not be in place for a full year until FY25. This response is in relation to the repeat finding from prior year, FY22, that the Court failed to implement adequate controls over federal expenditures due to not having purchase orders for the December 2021 Tornado Disaster related expenses and that the third party hired by the court to be administrator for FEMA project activity resulting in a misstated SEFA and inaccurate record keeping. This finding repeats the finding of SEFA misstatement (2022-003). The SEFA was overstated for the Disaster Grant Public Assistance Program FEMA. The Court hired a third party company to administer the grant submissions for the December 2021 Tornado Disaster, and this created a disconnect between the submission process and later reporting process for the SEFA form. At the time that the SEFA was prepared submissions and approvals for FEMA related expenses had just started to occur. All expenses were included in the submission, even those that later were deemed ineligible for FEMA or were determined to be only partially covered by FEMA. There are still expenses as of May 2024 that are in the appeal stage of application for FEMA reimbursement with uncertainty of whether they will be approved with federal funding or will be denied. For the future planning, in the event that another disaster requires the County to contract with another outside agency for FEMA submission, the Court will strengthen the controls in the reporting process as well as seek out guidance from DLG and/or auditors and/or others on accurately reporting partially covered FEMA expenses as well as expenses that are in an ‘unknown coverage’ state at the time of the SEFA creation. Additionally, the court will comply with auditor recommendations listed with these findings regarding future third party administrators.

View Audit 319322

Finding 496392 (2023-002)

Material Weakness 2023

The Geneva Foundation

WA

Special Tests & Provisions Subrecipient Monitoring Material Weakness

Finding 2023-002 Material weakness in internal controls and non-compliance related to special tests and provisions. Federal Agency: Department of Defense Pass-Through: N/A Assistance Listing Number: 12.420 Assistance Listing Name: Military Medical Research and Development Award Number: W81XWH-18-2-0...

Finding 2023-002 Material weakness in internal controls and non-compliance related to special tests and provisions. Federal Agency: Department of Defense Pass-Through: N/A Assistance Listing Number: 12.420 Assistance Listing Name: Military Medical Research and Development Award Number: W81XWH-18-2-0048 Period of Award: September 15, 2018 - September 14, 2024 Federal Agency: Department of Defense Pass-Through: N/A Assistance Listing Number: 12.750 Assistance Listing Name: Uniformed Services University Medical Research Projects Award Number: HU00011920056 Period of Award: October 1, 2019 - September 30, 2024 Federal Agency: U.S. Department of Health and Human Services Pass-Through: University of Utah Assistance Listing Number: 93.213 Assistance Listing Name: Research & Training in Complementary & Alternative Medicine Award Number: 10055443-02 Period of Award: September 22, 2020 - August 31, 2024 Criteria The National Institutes of Health and the Department of Defense require prior approval for a significant change in the status of key personnel including but not limited to withdrawal from the project; absence for any continuous period of 3 months or more; reduction of the level of effort devoted to project by 25 percent or more from what was approved in the initial competing year award. Condition/Context The Foundation’s internal controls require management to obtain prior approval for any significant changes or shortfalls of 25 percent or more of stated level of efforts in key personnel, from the award sponsor. During our testing, out of 22 grants tested, we noted 3 grants with instances where individuals identified as key personnel in the agreement either left the Foundation or had over 25% shortfall of level of efforts, and the sponsor was not timely notified. Our sample was not a statistical sample. Contact Person(s): Kristen Bacon, Director, Finance and Accounting. Corrective action planned: Geneva implemented the following increased measures in FY23 -- LOE operating procedures and JAMIS reports were developed to ensure that material LOE variances were detected, discussed, and if applicable, escalated to the sponsor. The Finance Office will revisit current LOE reports and if necessary, will enhance reporting to improve more visibility and completeness of LOE data by program. The Finance Office will also conduct a refresher training. As stated in the FY22 audit, management believes that review of financial and LOE reporting are clearly defined, documented, and are in compliance with accounting principles generally accepted in the United States of America and sponsor requirements; however, management will seek to strengthen the documentation, reporting, training, and communications between Finance and the Department of Programs. If process deficiencies are identified or Standard Operating Procedures are not current, updates will be made, and end user compliance training will be rolled out to ensure a clear understanding. Anticipated completion date September 30, 2024

View Audit 319290

Finding 496389 (2023-002)

Significant Deficiency 2023

Youthprise

MN

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

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Justice Children Exposed to Violence – Assistance Listing No. 16.818 2023-002: Internal Controls over Compliance and Other Matters L. Reporting Internal Control Over Major Programs SIGNIFICANT DEFICIENCIES Recommendation: We recommend Y...

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Justice Children Exposed to Violence – Assistance Listing No. 16.818 2023-002: Internal Controls over Compliance and Other Matters L. Reporting Internal Control Over Major Programs SIGNIFICANT DEFICIENCIES Recommendation: We recommend Youthprise document its review and approval process over reports and document report submission dates. Action Taken: Management agrees with this finding and has since corrected the deficiency effective Fall 2023. If questions arise regarding this plan, please call Talbrey Benson-Goupil at 612-464-8485. Sincerely yours, Talbrey Benson-Goupil Finance Director

View Audit 319284

Finding 496371 (2023-001)

Significant Deficiency 2023

Banner Health

AZ

Questioned Costs Internal Control / Segregation of Duties Reporting

Internal control deficiency and noncompliance over reporting of lost revenues attributable to coronavirus reported in the provider relief fund report. Management has reviewed this finding and agrees with the conclusion. There will be no additional provider relief fund reports submitted given this w...

Internal control deficiency and noncompliance over reporting of lost revenues attributable to coronavirus reported in the provider relief fund report. Management has reviewed this finding and agrees with the conclusion. There will be no additional provider relief fund reports submitted given this was the final report submitted to substantiate the payments received. However, if this program begins again, management will implement a control to ensure lost revenues are not duplicated. The entity will work with the grantor regarding the questioned costs identified. Contact Person: Paul Nolde-Morrissey, Corporate Controller Expected Completion Date: September 30, 2024

View Audit 319252 Questioned Costs: $1

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