Corrective Action Plans

Finding 49768 (2022-004)

Material Weakness 2022

Flat Rock - Haw Creek School Corporation

IN

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Finding 2022-004 ? Child Nutrition Cluster - Reporting Contact Person Responsible for Corrective Action: Melissa Dempsey Contact Phone Number: 812-546-2000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Lunch reimbursement claims ...

Finding 2022-004 ? Child Nutrition Cluster - Reporting Contact Person Responsible for Corrective Action: Melissa Dempsey Contact Phone Number: 812-546-2000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Lunch reimbursement claims will be reviewed by a secondary individual prior to submission to IDOE and signed off on to document the review. Anticipated Completion Date: April 2023

View Audit 42424 Questioned Costs: $1

Finding 49767 (2022-003)

Material Weakness 2022

Flat Rock - Haw Creek School Corporation

IN

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Finding 2022-003 ? Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Melissa Dempsey Contact Phone Number: 812-546-2000 Views of Responsible Official: We concur with the finding. Description of Correctiv...

Finding 2022-003 ? Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Melissa Dempsey Contact Phone Number: 812-546-2000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation will establish a documented review of all Child Nutrition Cluster account payable claims before they are paid. Additionally, the School Corporation will transfer funds to replenish the school lunch fund. Anticipated Completion Date: June 2023

View Audit 42424 Questioned Costs: $1

Finding 49757 (2022-004)

Material Weakness 2022

Hennepin County Minnesota

MN

Eligibility Subrecipient Monitoring Cash Management § 200.303

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2022-004?Eligibility Program: Medical Assistance Program (ALN 93.778) Type of Finding: Material Weakness in Internal Control over Compliance; Other Matter Compliance Finding Condition: During our testing, we noted the following insta...

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2022-004?Eligibility Program: Medical Assistance Program (ALN 93.778) Type of Finding: Material Weakness in Internal Control over Compliance; Other Matter Compliance Finding Condition: During our testing, we noted the following instances of noncompliance in the sample of 120 case files tested: ? One MAXIS case file had assets greater than their applicable household size asset limit. While beneficiaries may reduce their assets to continue to qualify, there was no documentation in the case notes showing the applicant reduced their assets subsequent to renewal in order to continue to qualify for benefits. ? One MAXIS case file had different bases of eligibility in MAXIS and MMIS where MAXIS indicated the beneficiary was ?EX? (age 65 or older) while MMIS indicated the beneficiary was ?DX? (disabled). ? One METS case file included documentation of verification of income that did not match the information entered into METS. ? One METS case file did not have a SSN entered at either the initial application date nor any of the subsequent renewal dates. No exemptions to the requirement to submit a SSN was noted in the case within METS. In addition, the County does not have effective internal controls over eligibility of the Medicaid program: ? The County does not have a formalized supervisory case file review process in place to ensure accuracy and completeness of inputs into the MAXIS and METS systems. ? We were not able to review and test the automated application controls and the related ITGCs within the MAXIS, METS and MMIS systems, all of which are state systems that are administered by the state and required to be used by the County, to determine whether the system controls are adequately designed and implemented and operating effectively for the determination of eligibility. Hennepin County?s Corrective Action Planned in Response to Finding: Program staff will design internal controls to ensure eligibility inputs are correctly entered, and information required by contract is retained. Hennepin County Employee Responsible for the CAP: Jackie Poidinger Planned Completion Date for CAP: December 31, 2023 Hennepin County will encourage the State to provide an independent audit of the design and implementation of MAXIS, METS, and MMIS system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2023

View Audit 51481

Finding 49756 (2022-005)

Significant Deficiency 2022

Hennepin County Minnesota

MN

Allowable Costs / Cost Principles Eligibility Student Financial Aid § 200.303

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2020-005?Eligibility Program: Foster Care Title IV-E (ALN 93.658) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While we were able to test manual compensating controls over activities allowed ...

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2020-005?Eligibility Program: Foster Care Title IV-E (ALN 93.658) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While we were able to test manual compensating controls over activities allowed or unallowed, allowable costs/cost principles and eligibility, we were not able to review and test the automated application controls and the related ITGCs within the MAXIS and SSIS systems that reside within the State of Minnesota, but are utilized by the County, to determine whether the system controls are adequately designed and implemented and operating effectively. Hennepin County?s Corrective Action Planned in Response to Finding: Hennepin County will encourage the State to provide an independent audit of the design and implementation of MAXIS and SSIS system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2023

View Audit 51481

Finding 49755 (2022-003)

Significant Deficiency 2022

Hennepin County Minnesota

MN

Matching / Level of Effort / Earmarking § 200.303 § 200.306

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2022-003?Matching Program: Continuum of Care Program (ALN 14.267) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While testing the matching requirement, we noted that internal controls are not pr...

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2022-003?Matching Program: Continuum of Care Program (ALN 14.267) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While testing the matching requirement, we noted that internal controls are not properly designed. While the County was able to provide documentation that the matching requirement was met, we noted the following: - The documentation to demonstrate that the required match was met was on a calendar-year basis for all grants in total instead of on the required grant-by-grant basis. - The data utilized in determining the match requirement was met was obtained from the State?s information system, MAXIS, and the County did not retain this data. - Reporting of the match on the HUD Annual Performance Report is completed by multiplying the total direct costs by the required match percentage instead of the actual match. - There was a lack of evidence that a supervisory review was periodically performed over matching. In addition, while we were able to test a manual compensating control over matching, we were not able to review and test the automated application controls and related ITGCs within the MAXIS system. The State was not able to provide information regarding the design and implementation of MAXIS system controls nor were we able to test those controls directly. Hennepin County?s Corrective Action Planned in Response to Finding: Program staff will establish internal controls which includes determination of the required match on a grant-by grant basis semi-annually and retain County records of reviews preformed. Hennepin County Employee Responsible for the CAP: Michael Radcliffe Planned Completion Date for CAP: December 31, 2023 Hennepin County will encourage the State to provide an independent audit of the design and implementation of MAXIS system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2023

View Audit 51481

Finding 49754 (2022-002)

Significant Deficiency 2022

Hennepin County Minnesota

MN

Subrecipient Monitoring Eligibility Significant Deficiency § 200.303

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2022-002?Eligibility Program: WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (ALN 10.557) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While testing the el...

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2022-002?Eligibility Program: WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (ALN 10.557) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While testing the eligibility requirement, we noted procedures and controls were not operating as designed to ensure that only those eligible were approved for WIC. In our sample of 40 cases, two cases had no evidence that an independent review of the eligibility determination occurred. In addition, while we were able to test manual compensating controls over eligibility determination, we were not able to review and test the automated application controls and the related information technology general controls (ITGCs) within the HuBERT system, a state system that is administered by the state and required to be used by the County for eligibility determination, to determine whether controls are adequately designed and implemented and operating effectively. Hennepin County?s Corrective Action Planned in Response to Finding: Program staff will establish a process to strengthen eligibility determinations. Hennepin County Employee Responsible for the CAP: Jill Wilson Planned Completion Date for CAP: December 31, 2023 Hennepin County will encourage the State to provide an independent audit of the design and implementation of HuBERT system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2023

View Audit 51481

Finding 49750 (2022-010)

Significant Deficiency 2022

Delaware State University

DE

Questioned Costs Reporting Significant Deficiency § 200.303

2022-010 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion ? Federal Assistance Listing Nos. 84.425E and 84.425F - Reporting Recommendation: We recommend the University enhances its procedures, controls, and review policie...

2022-010 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion ? Federal Assistance Listing Nos. 84.425E and 84.425F - Reporting Recommendation: We recommend the University enhances its procedures, controls, and review policies around HEERF reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Delaware State University?s Office of Business and Finance will create and upload the quarterly CARES HBCU and Institutional reports by the 10th day after the end of each calendar quarter. The Office of Student Accounts will create and upload the quarterly CARES Student Portion reports by the 10th day after the end of each calendar quarter. Name(s) of the contact person(s) responsible for corrective action: Assistant Controller, Sasha N. Lee & Executive Director of Student Accounts, Carold Boyer-Yancy. Planned completion date for corrective action plan: March 2023

View Audit 49440

Finding 49745 (2022-005)

Significant Deficiency 2022

Delaware State University

DE

Questioned Costs Student Financial Aid Significant Deficiency

2022-005 Student Financial Aid Cluster ? CFDA No. 84.268 ? Need Base Calculation Recommendation: We recommend that the University review the inputs of the calculation of need to ensure the non-need-based financial assistance is not included in need-based amounts. Explanation of disagreement with aud...

2022-005 Student Financial Aid Cluster ? CFDA No. 84.268 ? Need Base Calculation Recommendation: We recommend that the University review the inputs of the calculation of need to ensure the non-need-based financial assistance is not included in need-based amounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Financial Aid (OFA) has updated the packaging parameters for all scholarships in Ellucian Banner. For FY23 and forward, the full awards will be counted as estimated financial assistance and will not replace the EFC in students? need calculation. OFA will run reports throughout the awarding cycle, to identify students who are over awarded or overbudgeted; students? Federal and/or institutional resources will be adjusted accordingly. Name(s) of the contact person(s) responsible for corrective action: Executive Director of Financial Aid, Dorothy Fultz Planned completion date for corrective action plan: February 2023

View Audit 49440

Finding 49741 (2022-006)

Significant Deficiency 2022

Delaware State University

DE

Questioned Costs Student Financial Aid Reporting

2022-006 Student Financial Assistance Cluster ? CFDA Nos. 84.063 and 84.268 ? Enrollment Reporting Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the Univ...

2022-006 Student Financial Assistance Cluster ? CFDA Nos. 84.063 and 84.268 ? Enrollment Reporting Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review its policies and procedures on reporting enrollment information to the NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar?s Office will update policies, procedures and reporting practices to ensure timely submission to both the National Student Clearinghouse and the National Student Loan Database. Name(s) of the contact person(s) responsible for corrective action: Registrar, Jackie K. Brockington, Jr. Planned completion date for corrective action plan: July 2023

View Audit 49440

Finding 49735 (2022-003)

Material Weakness 2022

Walworth County Agricultural Society, Inc.

WI

Allowable Costs / Cost Principles Material Weakness Period of Performance

Reference Number: 2022-003 Description: Lack of Written Procedures for Federal Awards Corrective Action Plan: The Society will develop written procedures for federal awards received. Anticipated Corrective Action Plan Completion Date: ongoing Contact Information: For additional information regard...

Reference Number: 2022-003 Description: Lack of Written Procedures for Federal Awards Corrective Action Plan: The Society will develop written procedures for federal awards received. Anticipated Corrective Action Plan Completion Date: ongoing Contact Information: For additional information regarding this finding, please contact Larry Gaffey, General manager at 262-723-3228.

View Audit 49133

Finding 49730 (2022-013)

Material Weakness 2022

Pinecrest Academy of Northern Nevada

NV

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

Finding Number: 2022-013 ? SEFA Preparation Corrective Action Plan: In 2022, the office had downsized due to turnover in staff. While a process was in place for reconciling, a secondary review was not performed to verify accuracy of the residual value calculations. To strengthen the oversight of fin...

Finding Number: 2022-013 ? SEFA Preparation Corrective Action Plan: In 2022, the office had downsized due to turnover in staff. While a process was in place for reconciling, a secondary review was not performed to verify accuracy of the residual value calculations. To strengthen the oversight of financial management in the School, Academica Nevada, the School?s management company, has filled all the open positions and realigned staff responsibilities to reduce individual workloads and provide additional oversight and review. The grant manager will reconcile all grants to ensure proper cutoff, with a secondary review performed by a member of management. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

View Audit 43510

Finding 49722 (2022-003)

Material Weakness 2022

Boyceville Community School District

WI

Special Tests & Provisions Questioned Costs Material Weakness § 200.326

The District will carefully review any and all compliance requirements when using federal funding for future projects. Responsible person - Nicholas Kaiser. Anticipated completion date - ongoing.

View Audit 46293

Finding 49682 (2022-002)

Material Weakness 2022

Trimble Local School District

OH

Matching / Level of Effort / Earmarking Special Tests & Provisions Subrecipient Monitoring

Finding Number: 2022-002 Planned Corrective Action: The Treasurer/CFO is currently working on a federally funded project and has already reached out to the attorney and the contracts regarding the submittal of the payrolls for the projects. The attorney will review and confirm that they are followin...

Finding Number: 2022-002 Planned Corrective Action: The Treasurer/CFO is currently working on a federally funded project and has already reached out to the attorney and the contracts regarding the submittal of the payrolls for the projects. The attorney will review and confirm that they are following the Davis-Bacon Act rules and regulations. Anticipated Completion Date: December 31, 2023 Responsible Contact Person: Kevin Simons

View Audit 43480

Finding 49661 (2022-004)

Material Weakness 2022

Michigan State University

MI

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

Finding Number: 2022-004 Condition: The notifications related to the direct loan borrowers did not include information on the right to cancel or instructions on how to cancel the loans. Planned Corrective Action: The University?s new financial aid module does not have the capability to send emails. ...

Finding Number: 2022-004 Condition: The notifications related to the direct loan borrowers did not include information on the right to cancel or instructions on how to cancel the loans. Planned Corrective Action: The University?s new financial aid module does not have the capability to send emails. That functionality does exist in the University?s new student information system. Consequently, effective for Fall 2022 semester, the Office of Financial Aid partnered with Office of the Controller ? Student Accounts to generate emails on a weekly basis to any student who receives a disbursement of Title IV funds. By May 1, 2023 the University will create similar procedures to identify disbursements of Parent PLUS loans and then coordinate with Office of the Controller - Student Accounts to leverage the student information system to send notifications to parent borrowers. Contact person responsible for corrective action: Marshall Rumsey, Senior Associate Director, Office of Financial Aid Anticipated Completion Date: Completed September 8, 2022 (student), to be completed May 1, 2023 (parent)

View Audit 42191

Finding 49659 (2022-002)

Significant Deficiency 2022

Michigan State University

MI

Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking

Finding Number: 2022-002 Condition: The University did not reconcile the SAS data file to its institutional financial records. Planned Corrective Action: The Office of Financial Aid is now downloading the monthly file from COD and performing the reconciliation as required. Contact person responsible...

Finding Number: 2022-002 Condition: The University did not reconcile the SAS data file to its institutional financial records. Planned Corrective Action: The Office of Financial Aid is now downloading the monthly file from COD and performing the reconciliation as required. Contact person responsible for corrective action: Cheryl Whitman, Associate Director, Office of Financial Aid Anticipated Completion Date: April 1, 2023

View Audit 42191

Finding 49649 (2022-006)

Significant Deficiency 2022

Michigan State University

MI

Questioned Costs Student Financial Aid Significant Deficiency

Finding Number: 2022-006 Condition: The University did not obtain the correct tax return as part of the verification process. Planned Corrective Action: The University? initial understanding was that the new financial aid management database extracted the required data from the uploaded documents. ...

Finding Number: 2022-006 Condition: The University did not obtain the correct tax return as part of the verification process. Planned Corrective Action: The University? initial understanding was that the new financial aid management database extracted the required data from the uploaded documents. When it was discovered that this was not the case, the Office of Financial Aid disabled this functionality in the system and began reviewing all uploaded documents in January 2022 to confirm that they are the required documents. Contact person responsible for corrective action: Marshall Rumsey, Senior Associate Director, Office of Financial Aid Anticipated Completion Date: Completed January 1, 2022

View Audit 42191 Questioned Costs: $1

Finding 49648 (2022-005)

Material Weakness 2022

Michigan State University

MI

Questioned Costs Student Financial Aid Eligibility

Finding Number: 2022-005 Condition: The University awarded incorrect Pell awards to certain students based on the Pell Payment and Disbursement Schedule. Planned Corrective Action: The University?s new financial aid module was modified to use the census date for Pell recalculation rather than an arb...

Finding Number: 2022-005 Condition: The University awarded incorrect Pell awards to certain students based on the Pell Payment and Disbursement Schedule. Planned Corrective Action: The University?s new financial aid module was modified to use the census date for Pell recalculation rather than an arbitrary number of days into the term that did not match the University policy. The correction for this finding was implemented prior to aid being disbursed for the Fall 2022 semester. Contact person responsible for corrective action: Cheryl Whitman, Associate Director, Office of Financial Aid Anticipated Completion Date: Completed August 31, 2022

View Audit 42191 Questioned Costs: $1

Finding 49647 (2022-003)

Material Weakness 2022

Michigan State University

MI

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

Finding Number: 2022-003 Condition: The University used incorrect or incomplete data in the return of Title IV calculations. Planned Corrective Action: The new financial aid management database made incorrect R2T4 calculations and prevented manual adjustments to the calculations. The calculations ar...

Finding Number: 2022-003 Condition: The University used incorrect or incomplete data in the return of Title IV calculations. Planned Corrective Action: The new financial aid management database made incorrect R2T4 calculations and prevented manual adjustments to the calculations. The calculations are now done externally to the system and fixes and workarounds have been implemented to allow for the correct processing of R2T4 calculations. As of the Fall 2022 semester R2T4 calculations were being performed in the required timeframe. University personnel were not aware there was a shorter deadline (30 days versus 45 days) to return funds if the student had not begun attendance. Therefore, effective March 15, 2023, funds were being returned within 30 days for students for whom there is no confirmed attendance. Beginning with the fall 2022 semester, the Registrar?s Office has initiated procedures to confirm attendance/academic activity for courses that are dropped. This allows the University to identify whether adjustments need to be made to Pell grants before an R2T4 calculation is performed, and to determine if an R2T4 calculation is required or if all aid is to be returned for non-attendance. The withdrawal process itself has been modified to more clearly identify the withdrawal date. Contact person responsible for corrective action: Matthew Lyth, Financial Aid Officer Anticipated Completion Date: Completed March 15, 2023

View Audit 42191 Questioned Costs: $1

Finding 49646 (2022-001)

Material Weakness 2022

Michigan State University

MI

Student Financial Aid Material Weakness Reporting

Finding Number: 2022-001 Condition: The University did not report certain students' status to the NSLDS in an accurate and timely manner during the fiscal year. Planned Corrective Action: The University implemented a new administrative database for student academic records. The provided tool for ex...

Finding Number: 2022-001 Condition: The University did not report certain students' status to the NSLDS in an accurate and timely manner during the fiscal year. Planned Corrective Action: The University implemented a new administrative database for student academic records. The provided tool for extracting enrollment data did not perform as expected and hampered the school?s ability to provide the required data to the National Student Clearinghouse. The Registrar?s Office resolved its data collection issues and is now submitting the data to NSLDS via the Clearinghouse on the required timeline. Contact person responsible for corrective action: Becky Keogh, Senior Associate Registrar Anticipated Completion Date: Completed November 15, 2022

View Audit 42191

Finding 49601 (2022-002)

Material Weakness 2022

Rock County

WI

Questioned Costs Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2022-002 Program ALN: 93.498 Program Title: COVID-19 Provider Relief Funds Award Number/Year: Not applicable / 2022 Federal Agency: U.S. Department of Health and Human Services Repeat of Finding 2021-004 Condition Two of two reports selected for testing were not reviewed and appr...

Finding 2022-002 Program ALN: 93.498 Program Title: COVID-19 Provider Relief Funds Award Number/Year: Not applicable / 2022 Federal Agency: U.S. Department of Health and Human Services Repeat of Finding 2021-004 Condition Two of two reports selected for testing were not reviewed and approved by an independent person separate from the preparer prior to submission to HHS. In addition the County did not maintain supporting documentation to support the amounts reported. The sample was not statistically valid. Corrective Action Plan Corrective Action Planned: The next report due will include documentation of review and approval by an independent person separate from the preparer. In addition, supporting documentation to support the amounts reported will be maintained. Name(s) of Contact Person(s) Responsible for Corrective Action: Rock Haven Nursing Home Director and Rock Haven Business Manager. Anticipated Completion Date: The corrective action will be completed at the time the next report is due.

View Audit 42483

Finding 49594 (2022-005)

Material Weakness 2022

Taos Health Systems, Inc.

NM

Questioned Costs Cash Management HUD Housing Programs § 200.302 § 200.303

COVID-19 Provider Relief Fund ? AL No. 93.498 Recommendation: Our auditors recommended the Organization evaluate its financial reporting processes and controls to determine whether additional controls over the preparation of any Provider Relief Fund reports are needed to ensure the reports are prep...

COVID-19 Provider Relief Fund ? AL No. 93.498 Recommendation: Our auditors recommended the Organization evaluate its financial reporting processes and controls to determine whether additional controls over the preparation of any Provider Relief Fund reports are needed to ensure the reports are prepared in line with the Provider Relief Fund guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management?s response: The Organization missed reducing the costs claimed against PRF by the amounts reimbursed through the Medicare cost report. The Organization did have additional lost revenues though that would offset these costs claimed and wouldn?t result in a repayment of the funds. We would look to HRSA for guidance on how you would like us to update our Phase 1 PRF report or how you would like to see this corrected. Also, the CFO will listen to webinars to receive education for Phase IV funds that were received by the Organization to ensure compliance with the reporting requirements. COVID-19 Provider Relief Fund ? AL No. 93.498 (Continued) Name(s) of the contact person(s) responsible for corrective action: Connie Prewitt, Interim CFO Planned completion date for corrective action plan: Will implement in fiscal year 2023.

View Audit 42385 Questioned Costs: $1

Finding 49544 (2022-001)

Material Weakness 2022

Catholic Charities of the Texas Panhandle, Inc.

TX

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

Identifying Number: 2022-001 Audit Finding: Eligibility Requirements for Refugee and Entrant Assistance, Federal Assistance Listing Number 93.566 for 2022 issued by the US Department of Health and Human Services. (Repeat) Corrective Action Planned: Management of the Organization is requiring re...

Identifying Number: 2022-001 Audit Finding: Eligibility Requirements for Refugee and Entrant Assistance, Federal Assistance Listing Number 93.566 for 2022 issued by the US Department of Health and Human Services. (Repeat) Corrective Action Planned: Management of the Organization is requiring regular ongoing training for all federal programs. All files will be reviewed on a regular basis by a supervisor to ensure eligibility checklists have been used and completed and that all required documentation is contained in the files. The checklists themselves are being reviewed on a regular basis to ensure they reflect current federal guidelines. The biggest reason leading to this finding is that the checklists had not been signed off documenting review procedures were in place. We are now requiring staff to sign off on all checklists and are working to improve the checklists documentation to ensure that all internal controls are documented properly. We note that due to the large increase in the number of people being served, the organization has recently hired additional staff to maintain the content of the files to achieve compliance. Compliance managers will be assigned whose sole duty is to verify the required documentation exists in the files. The compliance managers will report to a supervisor who is independent of the program leadership. The name of the contact person responsible for the corrective action: Jeff Gulde, Executive Director The anticipated completion date: To be completed by March 31, 2023.

View Audit 42382

Finding 49535 (2022-001)

Material Weakness 2022

South Nassau Communities Hospital and Subsidiaries

NY

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

Finding 2022-001 ? Reporting Internal control deficiency and noncompliance over the calculation of lost revenues attributable to Coronavirus Identification of the federal program: Assistance Listing Number 93.498 Program Name: COVID-19 ? Provider Relief Fund Grantor: Department of Health and Human S...

Finding 2022-001 ? Reporting Internal control deficiency and noncompliance over the calculation of lost revenues attributable to Coronavirus Identification of the federal program: Assistance Listing Number 93.498 Program Name: COVID-19 ? Provider Relief Fund Grantor: Department of Health and Human Services (HHS) Federal award identification number: Not Applicable Views of responsible officials and planned corrective actions: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of lost revenues attributable to Coronavirus prior to future Portal submissions, where applicable. The error noted understated lost revenues in the Portal submissions by approximately $38 million and, as a result, will not result in a refund of funds to HRSA. In future reporting periods, management will add an additional layer of review focused on the detailed calculations prior to Portal submissions, where applicable. All stages of review will be formally documented via sign-offs by the appropriate members of management before the lost revenues are entered into future reporting Portal submissions. Management has contacted HRSA directly to inform them of the reporting errors and awaits next steps to address remediation as no Period 5 Portal submission is required. Management intends to revise their Period 3 and 4 lost revenue amounts to be in line with revised calculations. Contact person: John Pohlman Expected Completion Date: September 30, 2023

View Audit 46800

Finding 49532 (2022-001)

Material Weakness 2022

Indiana University Health, Inc. and Subsidiaries

IN

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

IU Health designed and implemented internal controls over the allowability of expenses and amounts submitted in the HRSA and ARP reports. These internal controls were precise enough to ensure that the submissions were compliant with HRSA reporting guidance. In fact, IU Health reached out directly to...

IU Health designed and implemented internal controls over the allowability of expenses and amounts submitted in the HRSA and ARP reports. These internal controls were precise enough to ensure that the submissions were compliant with HRSA reporting guidance. In fact, IU Health reached out directly to HRSA to confirm the appropriateness of its election. IU Health remained consistent in utilizing the annual budget as a basis for lost revenue past 2020. As inferred from the annual budget approval date threshold of March 27, 2020, our 2021 and 2022 budgets were prepared using prepandemic years as a baseline expectation. IU Health also conversed directly with HRSA wherein a representative confirmed our use of option 2 as appropriate for Period 3 and beyond, because, according to the representative, the intention of the written regulation did not literally mean budget approval for years past 2020 to have occurred prior to March 27, 2020. As our annual budgets were already naturally materially in line with our long-range plan that was approved in December of 2019, it seemed we were adhering to the spirit of the guidelines set forth. For future periods, IU Health will elect option 3 for lost revenue. Contact Person(s) Responsible for Corrective Action: David Burton Anticipated Completion Date: Effective for Period 5 deadline of September 30, 2023

View Audit 43374

Finding 49530 (2022-004)

Material Weakness 2022

Western Michigan University

MI

Matching / Level of Effort / Earmarking Questioned Costs Material Weakness § 200.328 § 200.329

Finding Number: 2022-004 Condition: The University did not file accurate and timely reports throughout the fiscal year. Planned Corrective Action: 1. The 9/30/21 HEERF institutional report was posted on the University?s website 10 days late. This was due to the staff member responsible going out...

Finding Number: 2022-004 Condition: The University did not file accurate and timely reports throughout the fiscal year. Planned Corrective Action: 1. The 9/30/21 HEERF institutional report was posted on the University?s website 10 days late. This was due to the staff member responsible going out on medical leave and miscommunication within the area on required filings. There were no additional quarterly reports to be filed so no further controls were put in place for this reporting. The annual report was filed timely. 2. The 9/30/21 institutional report has been removed from the University website as it indicated a duplicate expense that was reported on the 6/30/21 quarterly report. The 06/30/21 report has been marked as the final institutional report. 3. The Student Financial Aid (SFA) office agrees that the March 31, 2022, student website report did not include language regarding eligible students, and the reported student count was incorrect. SFA will amend the March 31, 2022, quarterly student report to reflect the correct number, add language regarding eligible students, and send the correction to the appointed HEERF email address by June 1, 2023. The Associate Director of Compliance and Training will perform a secondary review of any future reports to ensure the completeness and accuracy of the information. 4. The Student Financial Aid (SFA) office agrees that the 2021 annual report included the incorrect number of part-time graduate students who received an award, impacting the total number of students reported. The error was due to incorrectly inputting the information from the supporting data onto the annual report. SFA will amend the 2021 annual report by correcting the number of part-time graduate students by March 24, 2023. The Associate Director of Compliance and Training will perform a secondary review of the data on the annual report and compare it with the supporting documentation. 5. As indicated in the report, the University did comply with earmarking requirements. However, the categories used to report the expenditures on the 12/31/21 annual report were not the specific earmarked categories. The 12/31/21 annual report filed through the Department of Education website has just recently been made active again and the University will make necessary category reporting corrections. As the 12/31/21 annual report was the final report for institutional expenses no additional actions are required. Contact person responsible for corrective action: Colleen Scarff, Assoc VP for Business and Finance and Lana Greaves, Senior Associate Director, Student Financial Services Anticipated Completion Date: 3/24/23

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