Corrective Action Plans

Finding 372188 (2023-002)

Significant Deficiency 2023

OH

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding Number: 2023-002 Condition: Out of 60 allowability samples that were tested, one expenditure tested was determined to be incorrectly charged to this grant. Planned Corrective Action: The College of Cooperative Education and Professional Studies (CCPS) has instituted several reforms to prev...

Finding Number: 2023-002 Condition: Out of 60 allowability samples that were tested, one expenditure tested was determined to be incorrectly charged to this grant. Planned Corrective Action: The College of Cooperative Education and Professional Studies (CCPS) has instituted several reforms to prevent future instances of this nature. The Program Director is now required to review and sign-off on all transactions before they are charged to the project, to ensure all charges are appropriate. New staff have been assigned to the project to process transactions, and the CCPS business office is now meeting monthly to review project activity, discuss any questions, and address any concerns regarding financial activities. Additionally, the university is drafting a new policy to review and, if needed, provide additional administrative support for large, complex grant projects. This policy will require that grant proposals above a certain dollar threshold are reviewed by the Office of Research prior to submission to ensure proper resources will be available to manage the project if awarded. In cases where the Office of Research determines additional resources may be needed, they will be authorized to require additional support be included in the grant proposal, or else provide additional administrative help to the unit at the time of award. Contact person responsible for corrective action: CCPS: Jeremy Harvey, Jodi Sleyo, and Bailey Bartels. Office of Research: Patrick Clark Anticipated Completion Date: CCPS changes have been implemented as of 10/11/2023; policy changes to be completed by 6/30/2024.

View Audit 293505 Questioned Costs: $1

Finding 372175 (2023-001)

Significant Deficiency 2023

Montello School District

WI

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Finding #2023-001 -Limited Segregation of Duties (Prior Year Finding #2022-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected...

Finding #2023-001 -Limited Segregation of Duties (Prior Year Finding #2022-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected on a timely basis. Cause: The condition is due to limited staff available. Criteria: Internal controls should be in place that provide adequate segregation of duties. Generally, a system of internal control contemplates separation of duties such that no individual has responsibility to execute a transaction, have physical access to the related assets, and have responsibility or authority to record the transaction. Recommendation: Procedures should be implemented segregating duties among different employees. Management should continue to maintain a working knowledge of matters relating to the district's operations. Response: We agree with this finding and continue to work to achieve segregation of duties whenever cost effective. The cash disbursements process includes approval of purchase orders and matching of approved purchase orders with invoices. Review of account coding is perfo1med by the district accounting staff. The payroll disbursement process includes approval of timesheets and review of coding on an ongoing basis. The Board of Education reviews budget to actual information along with disbursement information monthly.

View Audit 293499

Finding 372135 (2023-001)

Material Weakness 2023

Alameda County Office of Education

CA

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

ACOE updated the new Time and Effort policy and offered agency-wide training.

View Audit 293447 Questioned Costs: $1

Finding 372133 (2023-002)

Material Weakness 2023

Lutheran Community Services Northwest

WA

Matching / Level of Effort / Earmarking Material Weakness Reporting

Finding 2023‐002 Material weakness in internal controls over compliance for earmarking and material noncompliance for earmarking in the U.S. Refugee Admissions Program. Contact Person(s): Nicholas Lee, Chief Financial Officer Corrective action planned: The accounting team will work alongside the pro...

Finding 2023‐002 Material weakness in internal controls over compliance for earmarking and material noncompliance for earmarking in the U.S. Refugee Admissions Program. Contact Person(s): Nicholas Lee, Chief Financial Officer Corrective action planned: The accounting team will work alongside the program management to develop and maintain a client tracker. Monthly meetings will be established to review spend, and resolve any questions. The client tracker will be established for the entire FYE June 30, 2024, and completed by August 31, 2024. The meetings will be established prior to the FYE June 30, 2024. Anticipated completion date: August 31, 2024

View Audit 293446

Finding 372131 (2023-002)

Significant Deficiency 2023

Western New Mexico University

NM

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Enrollment certifications will be sent to the National Student Clearninghouse on a monthly basis, no later than 10 days following the end of the month. The final degree file will be submitted no later than 30 days after the last day of class, with additional awards submitted individually. The Financ...

Enrollment certifications will be sent to the National Student Clearninghouse on a monthly basis, no later than 10 days following the end of the month. The final degree file will be submitted no later than 30 days after the last day of class, with additional awards submitted individually. The Financial Aid Director will review all NSLDS errors.

View Audit 293430

Finding 372130 (2023-002)

None 2023

Doane University

NE

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Doane has reviewed the finding and is researching ways to improve the process.

View Audit 293420

Finding 372129 (2023-001)

None 2023

Doane University

NE

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

The Financial Aid team is conducting staff training regarding return to Title IV calculations and compliance led by the Financial Aid Director. This includes all return to Title IV calculations being reviewed by the Financial Aid Director before final submission.

View Audit 293420 Questioned Costs: $1

Finding 372103 (2023-003)

None 2023

Avila University

MO

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Management is responsible for establishing a comprehensive information security policy to safeguard sensitive data. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective act...

Management is responsible for establishing a comprehensive information security policy to safeguard sensitive data. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2024. Corrective Action Plan: Management will continue to implement the remaining compliance requirements into a comprehensive policy.

View Audit 293383

Finding 372101 (2023-002)

None 2023

Avila University

MO

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Federal Direct Loan and Pell disbursement dates per the University's billing system did not agree with the reported dates per the Common Origination Disbursement (COD) records. Additionally, Pell award amount did not agree between the students' file and COD records. Personnel Responsible for Correct...

Federal Direct Loan and Pell disbursement dates per the University's billing system did not agree with the reported dates per the Common Origination Disbursement (COD) records. Additionally, Pell award amount did not agree between the students' file and COD records. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2024. Corrective Action Plan: Pell and Direct Loan origination records and disbursement records are submitted to the Common Origination Disbursement (COD) either same business day, or next business day. Formal reconciliation process is now completed every month in order to verify disbursement dates and amounts in COD.

View Audit 293383

Finding 372099 (2023-001)

Significant Deficiency 2023

Avila University

MO

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Enrollment information was not submitted accurately or within the required timeframe by the University. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will...

Enrollment information was not submitted accurately or within the required timeframe by the University. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2024. Corrective Action Plan: Management has hired a new Student Financial Services Director and is aware of the federal regulations surrounding enrollment information that must be reported to the NSLDS. Given the complexity of the reporting, management has established additional policies and procedures to address the errors related to enrollment reporting to the NSLDS in a timely and accurate manner.

View Audit 293383

Finding 372066 (2023-005)

Significant Deficiency 2023

City of East Prairie, Missouri

MO

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.403 § 200.403(F)

CORONAVIRUS STATE AND LOCAL RECOVERY FUNDS, ASSISTANCE LISTING 21.027 : INELIGIBLE COSTS / UNIFORM GUIDANCE 2 CFR PART 200 UNIFORM ADMINISTRATIVE REQUIREMENTS, COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL AWARDS, SUBPART E: COST PRINCIPLES SECTION 200.403(F) STATE "EXCEPT WHERE OTHERWISE AUTH...

CORONAVIRUS STATE AND LOCAL RECOVERY FUNDS, ASSISTANCE LISTING 21.027 : INELIGIBLE COSTS / UNIFORM GUIDANCE 2 CFR PART 200 UNIFORM ADMINISTRATIVE REQUIREMENTS, COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL AWARDS, SUBPART E: COST PRINCIPLES SECTION 200.403(F) STATE "EXCEPT WHERE OTHERWISE AUTHORIZED BY STATUTE, COSTS MUST MEET THE FOLLOWING CRITERIA IN ORDER TO BE ALLOWABLE UNDER FEDERAL AWARDS: (F) NOT BE INCLUDED AS A COST OR USED TO MEET COST SHARING OR MATCHING REQUIREMENTS OF ANY OTHER FEDERALLY-FINANCED PROGRAM IN EITHER THE CURRENT OR PRIOR PERIOD. / THE CITY OF EAST PRAIRIE RECEIVED ARPA FUNDS THROUGH MISSISSIPPI COUNTY, MISSOURI FOR THE REMOVAL OF ASBESTOS AND DEMOLITION OF A HAZARDOUS SCHOOL STRUCTURE IN ORDER TO FACILITATE THE CONSTRUCTION OF A PUBLIC HEALTH FACILITY IN AUGUST AND SEPTEMBER, 2022. IN DECEMBER OF THE SAME YEAR, THE CITY RECEIVED WAS AWARDED AND ARPA GRANT AND FUNDS THROUGH THE MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION FOR THE SAME PROJECT. THIS WAS A DUPLICATION OF ARPA FUNDS DUE TO THE CITY NOT BEING FULLY AWARE OF THE COST STANDARDS OF UNIFORM GUIDANCE AND A MISCOMMUNICATION REGARDING ELIGIBILITY OF COSTS. / THE CITY OF EAST PRAIRIE HAS CONTACTED MISSISSIPPI COUNTY AND WILL BE RECEIVING AUTHORIZATION FROM THE MISSISSIPPI COUNTY COMMISSION TO RE-ALLOCATE THOSE FUNDS FOR THE SAME PUBLIC HEALTH FACILITY PROJECT. WE ARE ALSO DEVELOPING A WRITTEN POLICY AND PROCEDURE MANUAL CONFORMING TO UNIFORM GUIDANCE.

View Audit 293337 Questioned Costs: $1

Finding 372060 (2023-001)

Material Weakness 2023

Coker University

SC

Allowable Costs / Cost Principles Material Weakness Reporting

Enrollment Reporting Name of contact person responsible for Corrective Action Plan: Whitney Costner, Registrar Corrective Action Plan: We concur with the finding. The University is currently implementing additional controls and procedures to ensure that all student roster files are reviewed, updated...

Enrollment Reporting Name of contact person responsible for Corrective Action Plan: Whitney Costner, Registrar Corrective Action Plan: We concur with the finding. The University is currently implementing additional controls and procedures to ensure that all student roster files are reviewed, updated, and submitted in accordance with applicable compliance requirements. Anticipated Completion Date: January 2024

View Audit 293336

Finding 371995 (2023-006)

Significant Deficiency 2023

Garrett-Evangelical Theological Seminary

IL

Student Financial Aid Allowable Costs / Cost Principles Reporting

Finding Number: 2023-006 Condition: Of the 9 students selected for enrollment reporting testing, the Seminary did not properly update student enrollment Information for 1 student in a timely manner. Planned Corrective Action: For students who finish their degree in December, they are reported as "wi...

Finding Number: 2023-006 Condition: Of the 9 students selected for enrollment reporting testing, the Seminary did not properly update student enrollment Information for 1 student in a timely manner. Planned Corrective Action: For students who finish their degree in December, they are reported as "withdrawn" as there is no option to confer in December (institutional policy). The student status is updated to "graduated" and reported to Clearinghouse in May when students are conferred. Contact person responsible for corrective action: Vince McGlothin-Eller, Registrar Anticipated Completion Date: 05/31/2024

View Audit 293235

Finding 371994 (2023-005)

Material Weakness 2023

Garrett-Evangelical Theological Seminary

IL

Student Financial Aid Material Weakness Matching / Level of Effort / Earmarking

Finding Number: 2023-005 Condition: During our review of internal controls and testing procedures, it was noted that no reconciliations could be provided. In addition, the Seminary does not have a quality assurance system in place. Planned Corrective Action: Within 1-2 weeks of each month's end, the...

Finding Number: 2023-005 Condition: During our review of internal controls and testing procedures, it was noted that no reconciliations could be provided. In addition, the Seminary does not have a quality assurance system in place. Planned Corrective Action: Within 1-2 weeks of each month's end, the Financial Aid Director requests a report from COD (US Department of Education Common Origination & Disbursement) for Direct Loans disbursed that month. That report is retrieved through EDConnect and reviewed. Financial Aid Director generates a report from Jenzabar Financial Aid system of Direct Loans disbursed for that month. The Financial Aid Director also retrieves a report of Direct Loans applied to students' accounts for that month from Business Office Senior Accountant. These three reports are then compared and reconciled for each month. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: Beginning 10/1/2023 (after first month of disbursement)

View Audit 293235

Finding 371993 (2023-004)

Material Weakness 2023

Garrett-Evangelical Theological Seminary

IL

Student Financial Aid Material Weakness Matching / Level of Effort / Earmarking

Finding Number: 2023-004 Condition: The Seminary did not maintain appropriate documentation to substantiate the allowable charges on the student's ledger account to identity whether credit balances were created and required additional documentation from the student to hold the credit balance Planned...

Finding Number: 2023-004 Condition: The Seminary did not maintain appropriate documentation to substantiate the allowable charges on the student's ledger account to identity whether credit balances were created and required additional documentation from the student to hold the credit balance Planned Corrective Action: Beginning with the Fall 2023 term, Title IV credit balances are no longer held past the 14 days with authorization from the student. The Financial Aid Director implemented a new policy where students cannot request that these funds are retained beyond 14 days. There is a shared list where the Business Office enters the date that the students’ credit balance was released to verify that process happens within 14 days. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 09/20/2023 (first day of Fall disbursement)

View Audit 293235

Finding 371991 (2023-002)

Material Weakness 2023

Garrett-Evangelical Theological Seminary

IL

Student Financial Aid Matching / Level of Effort / Earmarking Material Weakness

Finding Number: 2023-002 Condition: Of the 19 students who received disbursements selected for testing, the Seminary did not notify any of the students or parents, as applicable, that received direct federal loans within the required 30 days. Planned Corrective Action: Directly after a students’ Dir...

Finding Number: 2023-002 Condition: Of the 19 students who received disbursements selected for testing, the Seminary did not notify any of the students or parents, as applicable, that received direct federal loans within the required 30 days. Planned Corrective Action: Directly after a students’ Direct Loan is disbursed, Financial Aid Director manually sends the loan disbursement notification email to the student (through the Jenzabar financial aid system), which specifies the amount that they borrowed for the term and the right to cancel the loan within 14 days by emailing the Financial Aid Office. This email is recorded in the Jenzabar Financial Aid system. The Financial Aid Director also created a spreadsheet to track Direct Loan disbursements and notifications each term. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 09/20/2023 (first day of Fall disbursement)

View Audit 293235

Finding 371990 (2023-007)

Significant Deficiency 2023

Garrett-Evangelical Theological Seminary

IL

Student Financial Aid Eligibility Subrecipient Monitoring

Finding Number: 2023-007 Condition: The Seminary did not identify or provide the appropriate notification to a student that was not meeting the Seminary's policy on satisfactory academic progress (SAP). Planned Corrective Action: Satisfactory academic progress is now being monitored more carefully. ...

Finding Number: 2023-007 Condition: The Seminary did not identify or provide the appropriate notification to a student that was not meeting the Seminary's policy on satisfactory academic progress (SAP). Planned Corrective Action: Satisfactory academic progress is now being monitored more carefully. The Satisfactory academic progress report is run out of the student financial aid system. The internally generated report is reviewed by the Registrar and Financial Aid Director to confirm that student satisfactory academic progress statuses are correct. Once the appropriate status is confirmed, the Financial Aid Director will document students who are not in compliance with the institution’s policy and provide notifications to each student through email. The emails are recorded in the students' Jenzabar financial aid account. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 06/01/2024

View Audit 293235

Finding 371989 (2023-003)

Material Weakness 2023

Garrett-Evangelical Theological Seminary

IL

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles

Finding Number: 2023-003 Condition: The Seminary did not have controls in place to identify and document the students who have withdrawn and the applicability of performing a return of Title IV funds. Planned Corrective Action: Financial Aid Director has established a procedure to ensure that R2T4 c...

Finding Number: 2023-003 Condition: The Seminary did not have controls in place to identify and document the students who have withdrawn and the applicability of performing a return of Title IV funds. Planned Corrective Action: Financial Aid Director has established a procedure to ensure that R2T4 calculations are completed and any funds due to be returned are sent back to the Department of Education within 45 days of the date of the student's withdrawal. The Financial Aid Director created a listing to track all student withdrawals (including details of withdrawal). The Registrar sends an email to the Financial Aid Director notifying when a student has withdrawn from the institution, which gets entered onto the list. The Financial Aid Director set up the Department of Education's R2T4 calculator for the 2023-2024 academic year. R2T4 calculations are completed for any student withdrawn and if necessary, funds are returned to the Department of Education. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 09/05/2023 (beginning of Fall 2023 term)

View Audit 293235 Questioned Costs: $1

Finding 371924 (2023-009)

Significant Deficiency 2023

City of Albuquerque

NM

Matching / Level of Effort / Earmarking § 200.303

The City agrees with the finding. The Grant Administrator will work with City departments with construction contracts subject to wage rate requirements to ensure policies and procedures are documented and that a monitoring process is implemented to ensure adherence to established policies and granto...

The City agrees with the finding. The Grant Administrator will work with City departments with construction contracts subject to wage rate requirements to ensure policies and procedures are documented and that a monitoring process is implemented to ensure adherence to established policies and grantor requirements. This will be complete by June 30, 2024.

View Audit 293176

Finding 371921 (2023-007)

Significant Deficiency 2023

City of Albuquerque

NM

Procurement, Suspension & Debarment Significant Deficiency Matching / Level of Effort / Earmarking § 200.320

The City agrees with the finding. Over the past several years, the City has developed a significant number of guidance documents and trainings in the area of federal procurement. All of the guidance documents for Central Purchasing are housed in the Purchasing SharePoint site. The guidance and train...

The City agrees with the finding. Over the past several years, the City has developed a significant number of guidance documents and trainings in the area of federal procurement. All of the guidance documents for Central Purchasing are housed in the Purchasing SharePoint site. The guidance and training have in the past been directed at the members of the Purchasing Liaison User Group, but given the continued findings, the City intends to reach out to a much broader group to ensure compliance, including Directors, Deputy Directors, and program representatives. This will be complete by June 30, 2024.

View Audit 293176

Finding 371920 (2023-006)

Significant Deficiency 2023

City of Albuquerque

NM

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

The City agrees with the finding. Over the past several years, the City has developed a significant number of guidance documents and trainings in the area of federal procurement. All of the guidance documents for Central Purchasing are housed in the Purchasing SharePoint site. The guidance and train...

The City agrees with the finding. Over the past several years, the City has developed a significant number of guidance documents and trainings in the area of federal procurement. All of the guidance documents for Central Purchasing are housed in the Purchasing SharePoint site. The guidance and training have in the past been directed at the members of the Purchasing Liaison User Group, but given the continued findings, the City intends to reach out to a much broader group to ensure compliance, including Directors, Deputy Directors, and program representatives. In addition, during Fiscal Year 2023 the City implemented a new system, Contracts Life :Management (CUA), which includes an intake form in the federal funding section. The intake form includes the question "Is the supplier suspended or debarred?" The user is required to upload the result of the SAMS check search, regardless of the status of the contractor. When the answer is yes, the contract process is not allowed to proceed. The system is set up for social services and professional services only at this time, with a slow rollout of the rest of the types of City contracts over the next year or so. This system did not go-live with the existing professional services contracts until the end of the Fiscal Year and management believes that, with sufficient time and build out of the system, this system will help to reduce the exceptions noted above. In addition, as discussed above, management will review and revise internal policies and procedures as appropriate and ensure changes are communicated to departments. This will be completed by June 30, 2024.

View Audit 293176

Finding 371918 (2023-005)

Material Weakness 2023

City of Albuquerque

NM

Reporting Subrecipient Monitoring Eligibility § 200.302 § 200.303

The City agrees with the finding. The Treasury Portal automatically fills in the amounts for revenue loss for 2022 with amounts reported in 2020. The Treasury portal has many flaws that would cause errors in reporting. In addition, the portal has changed every quarter, which makes it challenging to ...

The City agrees with the finding. The Treasury Portal automatically fills in the amounts for revenue loss for 2022 with amounts reported in 2020. The Treasury portal has many flaws that would cause errors in reporting. In addition, the portal has changed every quarter, which makes it challenging to report accurately. The City will implement controls to ensure that a second review is completed prior to certification of the report. Additionally, the Grant Administrator will work with department staff responsible for reporting and ensure that each report's supporting documentation is complete and ties to underlying subrecipient reports, the general ledger and grantor reports. All supporting documentation, along with a copy of the submitted report, will be stored in a central location to ensure that they are available for subsequent reviews and audits. This will be completed by June 30, 2024.

View Audit 293176

Finding 371917 (2023-004)

Material Weakness 2023

City of Albuquerque

NM

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

The City agrees with the finding. The City will ensure that the federal report preparers reconcile all entries to program limitations prior to having the report submitted for final certification. This will be complete by June 30, 2024.

View Audit 293176

Finding 371751 (2023-004)

Material Weakness 2023

Cedars-Sinai Health System

CA

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

Finding 2023-004 Internal control deficiency and noncompliance over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting related to expenses attributable to coronavirus reported in the provider relief fund reports. The entity has excess lost revenues to cover all payment...

Finding 2023-004 Internal control deficiency and noncompliance over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting related to expenses attributable to coronavirus reported in the provider relief fund reports. The entity has excess lost revenues to cover all payments received (excluding the expenses submitted). Therefore, no refund is required for any payments received. Since the program has ended, the management has implemented the following procedures for future grants: 1) An education session occurred on February 15, 2024, with the relevant parties across Huntington Health entities to formally implement a review process whereby the Controller will review the support files prior to filings being made related to grant applications/programs across any of Huntington’s entities. Documentation of this review will be retained in the central file repository. These steps and controls will be updated and documented in the departmental policy. 2) A central folder on the Huntington Hospital’s main accounting drive has been created. This folder will be populated with all support for filed figures related to grant applications/programs across the hospital’s various entities. The support will be validated as having been placed into this folder as part of the reporting out process by the accounting manager and Controller handling the reporting. Files will be retained in this central drive for a minimum of 7 years. These steps and controls will be updated and documented in the departmental policy. Contact Person: Byron Davis, Controller and Steven Mohr, Senior Vice President and Chief Financial Officer, Huntington Hospital Anticipated Completion Date: Completed

View Audit 293159 Questioned Costs: $1

Finding 371633 (2023-001)

Significant Deficiency 2023

Cedars-Sinai Health System

CA

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

Finding 2023-001 Internal control deficiency and noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles related to salary cap limitation. In response to this finding management will implement the following: We are revising our internal controls to more frequently p...

Finding 2023-001 Internal control deficiency and noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles related to salary cap limitation. In response to this finding management will implement the following: We are revising our internal controls to more frequently perform our salary cap reconciliation ensuring the appropriate sponsor invoicing for employees who are over the salary cap limitation. For the salary cap variances that were identified through the previous reconciliation process, they will be adjusted and posted by the close of our March 2024 accounting period. Lastly, we will offset our cash for the March 2024 letter of credit draw down process in the Payment Management System, and incorporate adjustments in our March 2024 invoices for federal pass-thru awards. In addition, the salary cap adjustment program in our new ERP system was designed to remove the defect experienced in our legacy system. Contact Person: Nicole Anderson Leonard, Vice President, Research and Vice Dean Anticipated Completion Date: March 31, 2024

View Audit 293159

Corrective Action Plans

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