Corrective Action Plans

Finding 393880 (2023-010)

Material Weakness 2023

MI

Questioned Costs Cash Management Period of Performance § 200.305

The YWCA will implement the following changes in its accounting procedures. 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The C...

The YWCA will implement the following changes in its accounting procedures. 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The CFO will review the month and year noted by the Staff Accountant prior to entry into accounts payable.

View Audit 304072 Questioned Costs: $1

Finding 393879 (2023-009)

Significant Deficiency 2023

YWCA West Central Michigan

MI

Questioned Costs Cash Management Significant Deficiency § 200.305

The YWCA will implement the following changes in its accounting procedures. Each month, an aged open accounts payable report will be produced as part of the month end closing. Invoices that are past due will be paid in the following batch of payments (which are typically run weekly). If it is deter...

The YWCA will implement the following changes in its accounting procedures. Each month, an aged open accounts payable report will be produced as part of the month end closing. Invoices that are past due will be paid in the following batch of payments (which are typically run weekly). If it is determined that the invoice is not being paid for a valid reason, it will be removed from accounts payable at that time.

View Audit 304072 Questioned Costs: $1

Finding 393864 (2023-006)

Material Weakness 2023

YWCA West Central Michigan

MI

Questioned Costs Period of Performance Allowable Costs / Cost Principles

The YWCA will implement the following changes in its accounting procedures: 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The C...

The YWCA will implement the following changes in its accounting procedures: 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The CFO will review the month and year noted by the Staff Accountant prior to entry into accounts payable.

View Audit 304072 Questioned Costs: $1

Finding 393862 (2023-001)

Significant Deficiency 2023

City of Madison Alabama

AL

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.328

Finding 2023-001 The City concurs with the finding and will strengthen the policies and procedures in relation to grant reporting from award of grant to final report. It will be the policy of the City to assign an employee within the department receiving the grant to track, monitor, and file all req...

Finding 2023-001 The City concurs with the finding and will strengthen the policies and procedures in relation to grant reporting from award of grant to final report. It will be the policy of the City to assign an employee within the department receiving the grant to track, monitor, and file all required reports in a timely manner. This employee will also be required to forward copies of any grant awards, requirements, communications, and reports to the Finance Department in a timely manner. This will be implemented in April of 2024.

View Audit 304069

Finding 393769 (2023-001)

None 2023

Pepperdine University

CA

Student Financial Aid Eligibility Reporting

Enrollment Reporting Cluster: Student Financial Assistance Federal Awarding Agency: Department of Education (ED) Award Name: Federal Pell Grant Program, Federal Direct Student Loans Award Number: Not applicable Award Year: 2022-2023 Assistance Listing Title: Federal Pell Grant Program, Federal Direc...

Enrollment Reporting Cluster: Student Financial Assistance Federal Awarding Agency: Department of Education (ED) Award Name: Federal Pell Grant Program, Federal Direct Student Loans Award Number: Not applicable Award Year: 2022-2023 Assistance Listing Title: Federal Pell Grant Program, Federal Direct Student Loans Assistance Listing Number: 84.063 and 84.268 Pass-through entities: Not applicable Facts of Finding: The University uses National Student Clearinghouse (NSC) to help report enrollment status changes to National Student Loan Data System (NSLDS). For students that had a gap in enrollment and were no longer with the University, the NSC system recognized these students as “withdrawn” regardless of whether they were reported as “withdrawn” or “graduated.” The University confirmed these students were properly reported to NSC as “graduated”; however, when the reporting from NSC to NSLDS occurred, it was based on the information recognized by NSC, and as such these students were reported as “withdrawn.” Acceptance of Finding: We agree with the above finding and will implement the corrective plan of action as described below: Corrective Plan of Action: After submission of enrollment information to the NSLDS, the University has not historically verified that the NSLDS has updated students’ enrollment status accurately. The University will formalize a process and establish procedures to regularly identify students whose enrollment status is improperly reported to NSLDS, particularly those reported as “withdrawn” instead of “graduated.” To the extent there are discrepancies between the University’s records and these students’ enrollment status in NSLDS, the University will correct the enrollment status of such students in NSLDS accordingly. This process and related procedures will be established and implemented by the close of the current fiscal year, July 31, 2024.

View Audit 303962

Finding 393727 (2023-001)

Material Weakness 2023

Ahepa 310-Vii, Inc.

AL

Questioned Costs HUD Housing Programs Reporting

Finding 2023-001 - Supportive Housing for the Elderly, AL # 14.157 Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date August 3, 2023 Actions Taken or Planned on the Finding Management monitored the RAD for...

Finding 2023-001 - Supportive Housing for the Elderly, AL # 14.157 Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date August 3, 2023 Actions Taken or Planned on the Finding Management monitored the RAD for PRAC closing and received the Termination and Release of Section 202 Capital Advance Mortgage, Deed of Trust/Security Deed, Regulatory Agreement, Section 202 Capital Advance Use Agreement and Other Instruments. Contact Person First Name Dawn Contact Person Last Name Cole

View Audit 303897 Questioned Costs: $1

Finding 393726 (2023-001)

Material Weakness 2023

Ahepa 310-Vi, Inc.

AL

Questioned Costs HUD Housing Programs Reporting

Finding 2023-001 - Supportive Housing for the Elderly, AL # 14.157 Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date August 3, 2023 Actions Taken or Planned on the Finding Management monitored the RAD for...

Finding 2023-001 - Supportive Housing for the Elderly, AL # 14.157 Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date August 3, 2023 Actions Taken or Planned on the Finding Management monitored the RAD for PRAC closing and received the Termination and Release of Section 202 Capital Advance Mortgage, Deed of Trust/Security Deed, Regulatory Agreement, Section 202 Capital Advance Use Agreement and Other Instruments. Contact Person First Name Dawn Contact Person Last Name Cole

View Audit 303896 Questioned Costs: $1

Finding 393725 (2023-001)

Material Weakness 2023

Ahepa 310-V, Inc.

AL

Questioned Costs HUD Housing Programs Reporting

Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date August 3, 2023 Actions Taken or Planned on the Finding Management monitored the RAD for PRAC closing and received the Termination and Release of Section 2...

Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date August 3, 2023 Actions Taken or Planned on the Finding Management monitored the RAD for PRAC closing and received the Termination and Release of Section 202 Capital Advance Mortgage, Deed of Trust/Security Deed, Regulatory Agreement, Section 202 Capital Advance Use Agreement and Other Instruments. Contact Person First Name Dawn Contact Person Last Name Cole

View Audit 303895 Questioned Costs: $1

Finding 393724 (2023-001)

Material Weakness 2023

Ahepa 192-Iii, Inc.

IA

Questioned Costs HUD Housing Programs Reporting

Finding 2023-001 - Supportive Housing for the Elderly, AL # 14.157 Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date January 12, 2024 Actions Taken or Planned on the Finding Management agrees with the fin...

Finding 2023-001 - Supportive Housing for the Elderly, AL # 14.157 Concur or Do Not Concur with this Finding Concur Agree or Disagree with auditor recommendations Agree Completion Date or Proposed Completion Date January 12, 2024 Actions Taken or Planned on the Finding Management agrees with the finding and the funds were repaid on January 12, 2024. Contact Person First Name Dawn Contact Person Last Name Cole

View Audit 303893 Questioned Costs: $1

Finding 393702 (2023-001)

Material Weakness 2023

Planned Parenthood North Central States

MN

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

2023-001 Title X – Assistance Listing No. 93.217 Recommendation: We recommend management develop procedures to ensure the required reporting submitted to the funder is complete and accurate. Additionally, systems should be put in place to both track and report its progress on the non-federal share r...

2023-001 Title X – Assistance Listing No. 93.217 Recommendation: We recommend management develop procedures to ensure the required reporting submitted to the funder is complete and accurate. Additionally, systems should be put in place to both track and report its progress on the non-federal share requirement and any program income. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has initiated a review process to ensure the reporting is complete and accurate per the Federal Financial Report Instructions prior to submission. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: April 1, 2024

View Audit 303852

Finding 393688 (2023-003)

Significant Deficiency 2023

East Casey County Water District

KY

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Cash Management

The District has for many years adhered to the Uniform Guidance procurement codes as established under Section 200.320. The East Casey County Water District shall follow all State and Federal Guidelines as they relate to procurement.

View Audit 303825

Finding 393680 (2023-002)

Significant Deficiency 2023

Berlin Retirement Homes, Inc.

MA

Questioned Costs Matching / Level of Effort / Earmarking

Clinton Savings Bank has been added to the automatic journal entry as well as the transfer to the bank.

View Audit 303809 Questioned Costs: $1

Finding 393490 (2023-005)

Material Weakness 2023

City of Elizabeth

NJ

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

The City recognizes the importance of internal controls and plans to enhance procedures to ensure payroll expenditures related to grants are properly captured, documented, and charged to that grant. Covid interruptions with related illnesses, early retirements, and hiring difficulties all contribut...

The City recognizes the importance of internal controls and plans to enhance procedures to ensure payroll expenditures related to grants are properly captured, documented, and charged to that grant. Covid interruptions with related illnesses, early retirements, and hiring difficulties all contribute to a negative impact on productivity.

View Audit 303684 Questioned Costs: $1

Finding 393445 (2023-001)

Significant Deficiency 2023

Community Resource Project, Inc.

CA

Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking

The agency agrees with the material finding on improper cutoff and depreciation. The agency was following advice from their previous auditors and now learning the correct way to record these items Community Resource Project, Inc. will strive to implement changes immediately. Going forward the agency...

The agency agrees with the material finding on improper cutoff and depreciation. The agency was following advice from their previous auditors and now learning the correct way to record these items Community Resource Project, Inc. will strive to implement changes immediately. Going forward the agency will implement a procedure to properly cutoff end-of-year expenses and have already begun recording depreciation for grant funded vehicles in the correct manner. Person(s) Responsible: Elizabeth Bianchi-Rossi, Finance Director Timing for Implementation: February 2024 – Once the agency learned of these errors, Community Resource Project, Inc. have already implemented a new procedure for the cutoff period at the end of the year and have changed our depreciation method to ensure the full value of the vehicle gets depreciated.

View Audit 303663 Questioned Costs: $1

Finding 393370 (2023-004)

Significant Deficiency 2023

City of Fosston

MN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Special Tests & Provisions

Contact Person - Cassandra Heide, City Administrator Corrective Action Plan - Will establish a procedure to review certified payrolls. Completion Date - Immediately

View Audit 303628

Finding 393327 (2023-010)

Material Weakness 2023

Troy Public Schools

MT

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.326

FINDING 2023-010: Wage Rate Compliance Response: The District will implement internal controls to ensure that all construction vendor contracts will include prevailing wage clauses and weekly certified payrolls are received.

View Audit 303602

Finding 393254 (2023-028)

Material Weakness 2023

State of New Jersey

NJ

Subrecipient Monitoring Material Weakness Reporting § 200.303

Unlike other subgrants managed by the Department of Law and Public Safety (DLPS), the subgrants in the Public Assistance program are not issued by the Department but instead are issued by the Federal Emergency Management Agency (FEMA). These FEMA-issued subgrants take the form of Project Worksheets...

Unlike other subgrants managed by the Department of Law and Public Safety (DLPS), the subgrants in the Public Assistance program are not issued by the Department but instead are issued by the Federal Emergency Management Agency (FEMA). These FEMA-issued subgrants take the form of Project Worksheets (PWs) and are directly related to a specific disaster. FEMA informs the DLPS of the approved PWs after they are issued. Given the unique nature of the PW issuance, the DLPS is not in a position to report on the FFATA Subaward Reporting System (FSRS) at the time PWs are issued. This contrasts with other grant programs overseen by the DLPS, which do allow for timely subaward reporting in FSRS. The Department will continue to work with our FEMA partners, incorporating any guidance they provide, to develop procedures that ensure subawards are reported in FSRS within the FFATA reporting requirements. COMPLETION DATE/ CONTACT PERSON & PHONE# Fiscal Year 2024 and Ongoing Salvatore Marcello (609) 882-2000 ext.3046 Salvatore.Marcello@njsp.gov

View Audit 303516

Finding 393253 (2023-027)

Significant Deficiency 2023

State of New Jersey

NJ

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

The audit finding noted one Consultative Examination (CE) provider where the qualified provider review was not completed timely and this was an oversight on the part of the Department of Labor and Workforce Development’s Division of Disability Services (DDS) due to attrition of staff. Going forward...

The audit finding noted one Consultative Examination (CE) provider where the qualified provider review was not completed timely and this was an oversight on the part of the Department of Labor and Workforce Development’s Division of Disability Services (DDS) due to attrition of staff. Going forward, each DDS Professional Relations Officer will be responsible for reviewing eight to 10 CE provider’s qualifications each month until the yearly review is completed for each vendor. The Chief of Professional Relations will submit a monthly report to the DDS Assistant Director detailing how many sites were visited that month and any findings that may have occurred. Each month, the report will detail how many reports remain outstanding in order to complete the yearly reviews. COMPLETION DATE/ CONTACT PERSON & PHONE# April 9, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

View Audit 303516

Finding 393239 (2023-022)

Significant Deficiency 2023

State of New Jersey

NJ

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

There is no change to the prior year corrective action plan provided by the Department of Human Services, Division of Medical Assistance and Health Services (DMAHS) as corrective actions have been fully implemented as of January 2023. Current Managed Care Organization (MCO) contracts no longer cont...

There is no change to the prior year corrective action plan provided by the Department of Human Services, Division of Medical Assistance and Health Services (DMAHS) as corrective actions have been fully implemented as of January 2023. Current Managed Care Organization (MCO) contracts no longer contain the language requiring an audit conducted specifically in accordance with generally accepted accounting principles and generally accepted auditing standards and now specify that AUP reports are acceptable. Section 7.25.1(B) of the MCO Contract was updated effective January 2023 and removed the language requiring audits in accordance with generally accepted accounting principles and generally accepted auditing standards, and specifies that an AUP report is acceptable per guidance provided under Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) Frequently Asked Question number Q10. COMPLETION DATE/ CONTACT PERSON January 2023 Robert Durborow (609) 775-7298 Robert.Durborow@dhs.nj.gov

View Audit 303516

Finding 393233 (2023-020)

Material Weakness 2023

State of New Jersey

NJ

Subrecipient Monitoring Material Weakness Reporting § 200.303

The Department of Human Services’ Division of Family Development (DFD) agrees with the audit finding regarding the required submission of subawards to the FFATA Subaward Reporting System (FSRS). Due to the complexity and time required to compile and report FFATA subaward data, the DFD is in the pro...

The Department of Human Services’ Division of Family Development (DFD) agrees with the audit finding regarding the required submission of subawards to the FFATA Subaward Reporting System (FSRS). Due to the complexity and time required to compile and report FFATA subaward data, the DFD is in the process of creating a new full-time equivalent position (FTE) for this required federal reporting task. In accordance with the finding recommendation, the DFD will develop internal controls and procedures to ensure the timely reporting of all required subawards to FSRS. An initial review of the FSRS by DFD fiscal staff appeared to indicate that some federal grant award data that should be prepopulated by the awarding federal agency and available on the website was missing (e.g. Child Care M&M available; Discretionary not found). Staff will reach out to the necessary federal agencies to communicate instances of missing federal award information in an effort to ensure that the DFD has the ability to input the required subaward information. DFD anticipates that the assessment and development of policy and procedures related to this task will take approximately three (3) months. Staff assignment, training, and submission of federal grant subaward information to the federal website will occur over the next state fiscal year. COMPLETION DATE/ CONTACT PERSON Policy Completion Date: June 30, 2024 Implementation Date: Fiscal Year 2025 Thomas Mattaliano, CFO-DFD (609) 588-3370 Thomas.Mattaliano@dhs.nj.gov

View Audit 303516

Finding 393231 (2023-019)

Significant Deficiency 2023

State of New Jersey

NJ

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

The Department of Community Affairs (DCA) Low-Income Home Energy Assistance Program (LIHEAP) staff have been fully trained to coordinate with the Applied Public Policy Research Institute for Study and Evaluation (APPRISE) and the federal U.S. Department of Health and Human Services (HHS) to ensure t...

The Department of Community Affairs (DCA) Low-Income Home Energy Assistance Program (LIHEAP) staff have been fully trained to coordinate with the Applied Public Policy Research Institute for Study and Evaluation (APPRISE) and the federal U.S. Department of Health and Human Services (HHS) to ensure that all required reports are submitted timely. DCA has created a schedule of required reports that includes corresponding submission due dates and the process is designed to ensure adequate time is available to accommodate the necessary back and forth communications between DCA and APPRISE required to complete all reporting timely. COMPLETION DATE/ CONTACT PERSON April 30, 2024 Fidel Ekhelar (609) 815-3905 Fidel.Ekhelar@dca.nj.gov

View Audit 303516

Finding 393227 (2023-017)

Material Weakness 2023

State of New Jersey

NJ

Subrecipient Monitoring Material Weakness Reporting § 200.303

The Department of Community Affairs (DCA) has recently implemented timely reporting of required FFATA subaward data in the Federal Subaward Reporting System (FSRS). The FFATA reporting process is fully documented, and additional staff have been hired and trained on the process to further support the...

The Department of Community Affairs (DCA) has recently implemented timely reporting of required FFATA subaward data in the Federal Subaward Reporting System (FSRS). The FFATA reporting process is fully documented, and additional staff have been hired and trained on the process to further support the federal reporting functions. The FFATA reports identified by the auditors with inaccurate subaward amounts reported have also been corrected in FSRS. COMPLETION DATE/ CONTACT PERSON April 30, 2024 Fidel Ekhelar (609) 815-3905 Fidel.Ekhelar@dca.nj.gov

View Audit 303516

Finding 393222 (2023-014)

Material Weakness 2023

State of New Jersey

NJ

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

Based on the Corrective Action Plan (CAP) developed for the prior year FY 2022 audit finding cited for FFATA reporting, the Department of Health (DOH) Grants Unit, with coordination from the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) fiscal staff, added a new function to the ...

Based on the Corrective Action Plan (CAP) developed for the prior year FY 2022 audit finding cited for FFATA reporting, the Department of Health (DOH) Grants Unit, with coordination from the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) fiscal staff, added a new function to the System for Administering Grants Electronically (SAGE) that pulls all subaward data for the ELC program using the program’s 93.323 federal Assistance Listing Number (ALN). Thus, the CAP implemented in September 2022 for the prior year FY 2022 audit finding includes SAGE now pulling the subaward data for the entire ELC program by the ALN number and enables the ELC fiscal staff to access all ELC subawards within the DOH. ELC fiscal staff also has a task reminder set to report at the end of each month, enter subaward information into the FFATA Subaward Reporting System (FSRS), and upload each report submitted to the SharePoint ELC Document Library at the end of each month. As per the original CAP created under the FY 2022 audit, FFATA information for ELC subawards were entered into FSRS beginning on September 1, 2022 and DOH actions and efforts have continued to ensure compliance going forward. COMPLETION DATE/ CONTACT PERSON April 10, 2024 Rina Warehall (609) 913-5300 Rina.Warehall@doh.nj.gov

View Audit 303516

Finding 393220 (2023-013)

Material Weakness 2023

State of New Jersey

NJ

Subrecipient Monitoring Material Weakness Reporting § 200.303

The Department of Health’s (DOH) Vaccine Preventable Disease Program (VPDP) is in compliance with the Federal Funding Accountability and Transparency Act (FFATA) requirements with regard to reporting all active first-tier subawards of federal COVID-19 funds that DOH divisions have issued totaling $3...

The Department of Health’s (DOH) Vaccine Preventable Disease Program (VPDP) is in compliance with the Federal Funding Accountability and Transparency Act (FFATA) requirements with regard to reporting all active first-tier subawards of federal COVID-19 funds that DOH divisions have issued totaling $30,000 or greater under this Cooperative Agreement and COVID-19 Supplemental. However, it is not in compliance with regard to reporting required subaward data in FSRS by the end of the month following the month in which DOH has made the subawards totaling $30,000 or greater. The VPDP will continue to follow the DOH policy set forth in FMC 22-05 and report to FSRS all active first-tier subawards of federal COVID-19 funds DOH divisions have issued at $30,000 or greater under the COVID-19 Supplementals. The VPDP fiscal/grants leadership team will strive to ensure each of the identified subawards is entered on the FFATA Subaward Reporting System (FSRS) website by the end of the month following the month that DOH has made the subawards. VPDP will continue its efforts to bring the gap in reporting to FSRS down from five months presently to within the specified FFATA submission deadlines denoted above. VPDP also has on boarded a full-time Contract Administrator 2 who will be responsible for reporting FFATA data into FSRS for the Immunization Cooperative Agreement. COMPLETION DATE/ CONTACT PERSON April 4, 2024 Susan Barcarola (609) 943-5302 Susan.Barcarola1@doh.nj.gov

View Audit 303516

Finding 393215 (2023-012)

Significant Deficiency 2023

State of New Jersey

NJ

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

The Division of Aging Services (DoAS) implemented the FFATA reporting process in June 2023; however, DoAS fell behind on timely submission of FFATA reports due to staffing constraints. To address this issue, the DoAS plans to hire a fiscal analyst dedicated to managing FFATA reporting. DoAS is plann...

The Division of Aging Services (DoAS) implemented the FFATA reporting process in June 2023; however, DoAS fell behind on timely submission of FFATA reports due to staffing constraints. To address this issue, the DoAS plans to hire a fiscal analyst dedicated to managing FFATA reporting. DoAS is planning to be up-to-date on FFATA reporting and timely submission within 90 days. COMPLETION DATE/ CONTACT PERSON June 30, 2024 Hetal Bhatt (609) 438-4586 Hetal.Bhatt2@dhs.nj.gov Dennis McGowan (609) 438-4739 Dennis.McGowan@dhs.nj.gov

View Audit 303516

Corrective Action Plans

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