Corrective Action Plans

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Finding 391403 (2023-002)
Significant Deficiency 2023
The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are r...
The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are recognized in accordance with cost principles, statues, regulations, and terms and conditions of federal awards.
Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.033, 84.007 Recommendation: We recommend the College implements a formalized yearly reconciliation of Federal Work Study, Perkins, and Supplemental Education Opportunity Grants. Explanation of disagreement with audit fi...
Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.033, 84.007 Recommendation: We recommend the College implements a formalized yearly reconciliation of Federal Work Study, Perkins, and Supplemental Education Opportunity Grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: FWS: Jeff Younge, Director of Financial Aid, directs Business Office on when to pull funds. Reconciliation between financial aid system and payroll system is done annually, prior to end of fiscal year by Director of Financial Aid. Piece we will add is for Director of Financial Aid to verify amounts requested to be pulled actually got pulled by Business Office. This has not been a problem, but additional step will serve as an extra safeguard so that all stays in balance. Perkins: No new Perkins loans are being made. Annual FISAP serves as reconciliation for this program. SEOG: Jeff Younge, Director of Financial Aid, directs Business Office on when to pull funds at time of disbursement. Piece we will add is for Director of Financial Aid to verify amounts requested to be pulled actually got pulled by Business Office. This has not been a problem, but additional step will serve as an extra safeguard so that all stays in balance. Name of the contact person responsible for corrective action: Jeff Younge, Director of Financial Aid Planned completion date for corrective action plan: 3/26/2024
Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend the College implements policies to review all student award packages at the start of the academic year to ensure no over awards exist. Explanation of disagreement...
Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend the College implements policies to review all student award packages at the start of the academic year to ensure no over awards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office looks for over award situations throughout the academic year, as changes to Cost of Attendance and financial aid (Scholarships/Grants, Loans, and Work- Study earnings) can change throughout the year. That said, Financial Aid Staff (Jeff Younge and/or Sally Sorensen) will review every student for potential over awards during the 1st two weeks of fall semester (beginning August 20, 2024), to catch any over awards that may have been created between the time of packaging, and beginning of the academic year. Name of the contact person responsible for corrective action: Jeff Younge, Director of Financial Aid Planned completion date for corrective action plan: 3/26/2024
View Audit 301916 Questioned Costs: $1
Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation ...
Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Issue: Taylor Theiste began official withdrawal process on 1/31/23. This date was used in Return of Title IV calculations, and entered into PowerFAIDS system. Student was asked to unenroll from the courses by the Registrar, which she did, but not until 2 days later. Resolution: Jeff Younge (Director of Financial Aid) met with Sergio Salgado (Registrar) and Lisa Shubert (Manager of Administrative Computing and Institutional Reporting) on 11/29/23. Going forward, when student indicates intent to withdraw, Registrar will unenroll the student from courses using the withdrawal date used for Title IV purposes. This will ensure that the correct date is reported to Clearinghouse, and then to NSLDS. Issue: Ben Draper began official withdrawal process on 1/20/23. Since this was the 10th day of class, he was not included in the Census Report that was run at the end of the day (although correct date was used for Return of Title IV calculations, and transcript shows Ws). Consequently, he was treated for reporting purposes as if he did not return for spring semester, and withdrawal date sent to Clearinghouse, and then on to NSLDS, reverted to last day of the previous fall semester, which was 12/15/22. Resolution: On December 20, 2023, meeting was held in Luther Hall that included the following: (Stacey Dawley, Jeff Lemke, Jason Lowrey, Ted Manthe, Daniel Mundahl, Sergio Salgado, Lisa Shubert, Renee Tatge, Estelle Vlieger, Jeff Younge) Proposal was made (and accepted by this group, and later the President) that stated the following: 1. Add/Drop period is day 1-5 of fall and spring semester. During this time, classes can be added, and dropped courses disappear from student schedule/transcript, as if student did not begin the class. Courses withdrawn from after 5th day result in a grade on the transcript (W, WP/WF, or F, depending on the timing of the withdrawal). This is the current policy, not a proposed change. 2. Change wording of refund policy, so that instead of Week 1, Week 2, Week 3...it is worded as Day 1-5, Day 6-10, Day 11-15... (This solves the issue of 1st week being only 4 days in the fall, but 5 days in the spring, and the day after Labor Day being the 10th day of class, but 3rd week of the semester). 3. Change Census report figures from being (10th day) to (end of 5th day). That does not mean census report is available on the 5th day, but just that the information is “locked” as of that day for reporting purposes. Name of the contact person responsible for corrective action: Jeff Younge, Director of Financial Aid Planned completion date for corrective action plan: 3/26/2024
Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit fin...
Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024
View Audit 301912 Questioned Costs: $1
Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is...
Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024
View Audit 301912 Questioned Costs: $1
Finding 391301 (2023-006)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and review regulations set by the Department of Education around NSLDS to ensure the College understands the definitions for each enrollment information that gets re...
Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and review regulations set by the Department of Education around NSLDS to ensure the College understands the definitions for each enrollment information that gets reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college will evaluate our procedures and review regulations to ensure the appropriate enrollment information is reported, timely. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid and Michael Reig – Registrar. Planned completion date for corrective action plan: June 30, 2024
Finding 391297 (2023-005)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend reviewing the report that is run to identify withdrawn students to understand why these students were not included, as well as implement a compensating control to ensure future students...
Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend reviewing the report that is run to identify withdrawn students to understand why these students were not included, as well as implement a compensating control to ensure future students are not missed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office fully understands federal requirements surrounding the completion of R2T4s and strive to remain up to date with R2T4 best practice. We are fully committed to identifying the root cause, implementing corrective actions, and improving the system to prevent similar issues in the future. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid and Michael Reig – Registrar. Planned completion date for corrective action plan: April 30, 2024
Finding 391296 (2023-004)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the College review its policies and procedures around sending exit counseling information to students to ensure students are receiving proper counseling. Explanation of disagreement with audit finding: There i...
Student Financial Aid Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the College review its policies and procedures around sending exit counseling information to students to ensure students are receiving proper counseling. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Action taken in response to finding: We have conducted a thorough review of our exit counseling procedures and have identified areas of opportunity. Our team is committed to making the necessary corrections to ensure compliance with regulatory requirements. Our goal is to enhance our exit counseling program to better support students in understanding their rights and responsibilities regarding their federal student loans. We will execute this plan by including exit notices in our biweekly notifications, emailing students once an R2T4 is completed and notifying students that are less than halftime students the day after add/ period of each semester. For graduating students, we will host an event leading up to graduation where students can learn about the repayment process and an opportunity for students to complete their exit counseling. . Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid Planned completion date for corrective action plan: April 30, 2024
Finding 391294 (2023-003)
Significant Deficiency 2023
Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreem...
Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Financial Aid policies and procedures will be reviewed and amended as necessary. In conjunction with the Registrar’s Office all student changes and information will be reported and reconciled timely. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid Planned completion date for corrective action plan: September 30, 2024
Federal Direct Loans Reconciliations Planned Corrective Action: The University’s Financial Aid Office will review the reconciliations to ensure that the Direct Loan Program is reconciled. We will also refer the ED announcement DL-22-07 to maintain consistent and accurate reconciliations. Person ...
Federal Direct Loans Reconciliations Planned Corrective Action: The University’s Financial Aid Office will review the reconciliations to ensure that the Direct Loan Program is reconciled. We will also refer the ED announcement DL-22-07 to maintain consistent and accurate reconciliations. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024
Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates...
Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates reflect the actual disbursement date. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024
Finding 391242 (2023-003)
Significant Deficiency 2023
SD Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdowns and reports prior to submission. Explanation of disagreement with audit finding: There is no disag...
SD Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdowns and reports prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will designate a separate individual to review and approve the cash reimbursement requests and reports prior to submission. Name(s) of the contact person(s) responsible for corrective action: Tracy Johnson, Director of Finance Planned completion date for corrective action plan: June 30, 2024
Finding No. 2023-004: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 14.218 - CDBG – Entitlement Grants Cluster Audit Recommendation: We recommend that the City establish procedures to ensure that subawards are uploaded to the FSRS system timely. Administration’...
Finding No. 2023-004: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 14.218 - CDBG – Entitlement Grants Cluster Audit Recommendation: We recommend that the City establish procedures to ensure that subawards are uploaded to the FSRS system timely. Administration’s Comments: The City will establish and follow policies and procedures to ensure that subawards are uploaded to the FSRS system timely. City will establish roles to improve execution of the reporting process. Anticipated Completion Date: June 30, 2024 Contact Person(s): Timothy Ho, Department of Community Services, Planner VII Holly Kawano, Department of Budget and Fiscal Services, Federal Grants Coordinator
Corrective Action With the organization of the Business Office under the new Business Administrator, the Charter School has implemented a system that utilizing docuware support to ensure that supporting schedules and documents for claims are readily available and ensure proper safekeeping of pertine...
Corrective Action With the organization of the Business Office under the new Business Administrator, the Charter School has implemented a system that utilizing docuware support to ensure that supporting schedules and documents for claims are readily available and ensure proper safekeeping of pertinent documents. In addition, this supports that the Charter School maintains supporting documentation for seven (7) years and making it available to the NJDOE, the U.S. Department of Education, and/or their authorized representatives upon request. Person(s) Responsible Bernadette Pinto, Interim School Business Administrator Planned Completion Date June 30, 2024
Based on FY2022 findings, Higher Horizons implemented internal control policies and procedures, effective May 1, 2023. The procedures address all the segregation of duties from journal entries to posting, reconciliation to reporting, and access to the accounting software. The implementation of the i...
Based on FY2022 findings, Higher Horizons implemented internal control policies and procedures, effective May 1, 2023. The procedures address all the segregation of duties from journal entries to posting, reconciliation to reporting, and access to the accounting software. The implementation of the internal control policies and procedures were initiated in May and June of 2023 (the last two months of FY 2023). During FY2024, these procedures were enforced to mitigate risks due to lack of sound internal control. To further strengthen the internal control system, Higher Horizons changed the requisition and accounts payable paper-based to paperless (electronic) process effective July 1, 2023. The electronic requisition system (Microix) is integrated with the accounting software (Abila), which has noticeably enhanced the internal control system.The Microix electronic requisition system eliminates the need to monitor the flow of paper documents, eliminates the risk of losing documents, and disallows purchases without approval. Microix features also require allowability of requisitions to be determined, all changes & communications to be captured, eliminates re-keying the information into Abila, minimizes manual interventions in entering & posting transactions, and much more. Higher Horizons will continue assessing & monitoring the effectiveness of our internal control, review the outcomes, and as needed, will further strengthen the process. Higher Horizons will monitor individual access to general ledger, subsidiary ledger, assets of the organization, accounting software, and Paycom. Access control procedures will be developed and implemented before the end of May 2024. As indicated in FY2023 audit findings, one of the causes for inadequate segregation of duties is the small number of staff in the Finance Department. Higher Horizons will contract with a finance consultant to review the current finance department staffing structure. The consultant will provide feedback and recommendation for adequately staffing the finance department to ensure segregation of duties. The finance management staff will conduct a comprehensive study of accounting and financial tasks, policies and procedures, and standard operating procedures by contracting the financial consultant before the end of June 2024. The study will be presented to the Board for approval, and OFC and OHS for funding.
Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2022 – 06/30/2023 Contract Number: FSCWJ00302 Award Year: 2022 – 2023 Comments on Findings and Recommendations: Finding 2023-001—Certification over payroll cost allocation (Control Finding)— Envision Un...
Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2022 – 06/30/2023 Contract Number: FSCWJ00302 Award Year: 2022 – 2023 Comments on Findings and Recommendations: Finding 2023-001—Certification over payroll cost allocation (Control Finding)— Envision Unlimited allocated staff salaries and related fringe benefits to the federal program based on budgeted estimates, which were determined before the services were provided. There was no employee certification or documented review of actual time and effort incurred for the payroll costs charged to the grant at the time audit procedures were performed. 2 CFR 200.430(i) Standards for Documentation of Personnel Expenses (1) Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to federal awards, but may be used for interim accounting purposes, provided that the non-federal entity's system of internal controls includes processes to review after-the-fact interim charges made to a federal award based on budget estimates. All necessary adjustments must be made such that the final amount charged to the federal award is accurate, allowable, and properly allocated. Action Taken- Employee certifications were obtained and reviewed by supervisors for all grant payroll costs charged during the award year and were provided to the auditors. A new process is in place for quarterly certifications to follow 2CFR 200.430(i). The required corrective action for Finding 2023-001 for the period 07/01/2022 – 06/30/2023 was completed in December 2023. The person now responsible for completion of the corrective action plan is Dennis James, Chief Financial Officer.
The Authority will perform an internal review of the toll credits usage Excel spreadsheet and will reconcile all credits used by the projects with a starting date in FY 2023 and later with the last version of the Federal-Aid Project Agreement approved by FHWA. Also, the credits summary will be deliv...
The Authority will perform an internal review of the toll credits usage Excel spreadsheet and will reconcile all credits used by the projects with a starting date in FY 2023 and later with the last version of the Federal-Aid Project Agreement approved by FHWA. Also, the credits summary will be delivered on a quarterly basis to the Executive Staff for the approval process. For the fiscal year 2024, the manual process of reconciling toll credits balance of the new projects with a starting date of January 2024 and later will be changed to an automated process with the PMIS Program, as agreed in Section II of the Memorandum of Understanding (MOU) signed in February 2016 between FHWA and the Authority. In addition, current toll credits tracking, reconciliation, and approval processes are reviewed by FHWA PR Division for compliance. Responsible: Mr. Enrique J. Rosa Torres, Budget Office Auxiliary Director Status: In process. Expected to be completed on or before June 30, 2025.
Corrective Action Plan: The Authority assigned an Analyst and a Supervisor the responsibility to monitor compliance with all related Federal requirements for the reporting process of these funds. Also, an adequate training was provided to the personnel involved in the administration of this program....
Corrective Action Plan: The Authority assigned an Analyst and a Supervisor the responsibility to monitor compliance with all related Federal requirements for the reporting process of these funds. Also, an adequate training was provided to the personnel involved in the administration of this program. Responsible: Mr. Ramon L. Rivera Rivera, Analyst Mr. Enrique J. Rosa Torres, Budget Office Auxiliary Director Status: Completed on June 30, 2023.
Management’s response - New management in place starting in February 2023 will ensure that the Town reviews and correctly separates these items going forward.
Management’s response - New management in place starting in February 2023 will ensure that the Town reviews and correctly separates these items going forward.
Finding 391171 (2023-004)
Significant Deficiency 2023
Finding 2023-004 Reporting Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantor: State of Missouri, State Emergency Management Agency Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially D...
Finding 2023-004 Reporting Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantor: State of Missouri, State Emergency Management Agency Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers: Project# 699963 P/W# 624; Project# 185883 P/W# 529; and Project# 150136 P/W# 171 Condition: Timeliness and submission of the quarterly reports required by the State of Missouri could not be verified. Views of Responsible Officials and Planned Corrective Actions: The state of Missouri requires all quarterly reports be mailed. While we did send in our quarterly reports to the state of Missouri as required, we do not have proof of submissions as we did not send by certified mail. All future quarterly reporting will be documented with an email to our State SEMA representative when we send out quarterly reports so there is documentation for our records. Responsible Party: Emily Bruening, Director – Finance Date of Completion: This will be implemented for our next round of quarterly reporting, due in April 2024.
Finding 391170 (2023-003)
Material Weakness 2023
Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansa...
Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Views of Responsible Officials and Planned Corrective Actions: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will implement testing of our inventory system (Lawson) to ensure calculations are accurate. All review and approvals of capital equipment will be maintained in Strata. Responsible Party: Jill McCart, VP Accounting and Reporting Date of Completion: By 6/30/24
View Audit 301777 Questioned Costs: $1
Finding 391169 (2023-002)
Significant Deficiency 2023
Finding 2023-002 Reporting Information on the federal program: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distrib...
Finding 2023-002 Reporting Information on the federal program: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (“PRF”) Payment Received Period: 01/01/2020–12/31/2022 (Period 4) and 01/01/2020–06/30/2023 (Period 5) Condition: For one of the sampled PRF reports (Mercy Hospital South Period 5 PRF Report), the amount reported for net patient service revenue (NPSR) for calendar year 2023 quarter 2 (CY2023 Q2) was incorrect for one reporting tax identification number (TIN). Views of Responsible Officials and Planned Corrective Actions: One cost report adjustment for the current year was inaccurately labeled as a prior year adjustment. This was an isolated oversight by our revenue analysis team. We will perform additional review of cost report adjustments used for PRF funding to ensure the amounts reported are accurate and in compliance with the terms of the agreement. Responsible Party: Kathryn Stecich, Executive Director, Revenue Cycle Date of Completion: By 6/30/24
Finding 391168 (2023-001)
Material Weakness 2023
Finding 2023-001 Activities Allowed or Unallowed Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (AR...
Finding 2023-001 Activities Allowed or Unallowed Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (“PRF”) Award Period of Performance: 01/01/2020–12/31/2022 (Period 4) and 01/01/2020–06/30/2023 (Period 5) Condition: Management performed a duplication of benefits analysis to ensure expenses to be used to substantiate PRF funding received were not reimbursed or obligated to be reimbursed by another source. The methodology included the development of estimated cost reimbursement rates by location that was applied to the PRF expenditures. During our allowable costs testing of expenditures, we noted errors in the duplication of benefits analysis and/or misapplication of the estimated cost reimbursement rates which resulted in a net overstatement of expenses totaling $2,078,408. In addition, we noted instances where employees’ hours reported on the timecards for substantiation of funding for the federal program were not consistently evidenced as reviewed and approved. Views of Responsible Officials and Planned Corrective Actions: While we overstated the expenses submitted totaling $2.1 million, this was an oversight during our review process. There are additional expenditures available in excess of funding received; therefore, we believe we have incurred either lost revenues or expenditures in excess of funding received. We will perform additional review of expenditures including the duplication of benefits analysis and application of the cost reimbursement rates to ensure appropriate amounts are used for PRF funding and ensure compliance with the terms of the agreement. Mercy Health’s Finance team will continue to stress the importance of timecard approval to leadership. Responsible Party: Jill McCart, VP Accounting and Reporting Date of Completion: By 6/30/24
View Audit 301777 Questioned Costs: $1
Finding #2023-002 – Elementary and Secondary School Emergency Relief Fund (ESSER) III Plan Condition: The District did not make its ESSER III Local Educational Agency (LEA) Plan Report readily and publicly available. Effect: By not making the plan available to the public, the District is effectivel...
Finding #2023-002 – Elementary and Secondary School Emergency Relief Fund (ESSER) III Plan Condition: The District did not make its ESSER III Local Educational Agency (LEA) Plan Report readily and publicly available. Effect: By not making the plan available to the public, the District is effectively not compliant with the Federal requirements for this program. Cause: The District was not aware of this requirement. Criteria: The OMB Compliance Supplement mandates a LEA to submit and make publicly available a plan for the safe return to in-person instruction and continuity of services, and the planned use of the ESSER III funding. Recommendation: The auditors recommend that the plan be made available on the District’s website. Response: We (the District) will upload the plan to the District’s website in order to make it publicly available. Cambridge School District’s Corrective Action Plan: The ESSER plans were posted on the district website until summer of 2023 when the website design was updated and information was migrated to new pages or eliminated if it was no longer relevant. As the ESSER LEA plan was associated with our COVID response plan and COVID related protocols were eliminated, the plan was removed. We were unaware that the plan needed to remain posted through the grant period. When we learned that the requirement to post the plan remains a requirement we promptly posted our WI DPI approved plan from DPI under the heading District Annual Notices. Contact Person: Margaret M. Banker, District Administrator/Business Manager Anticipated Completion Date: 9/01/2024
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