Corrective Action Plans

Finding 529065 (2024-011)

Significant Deficiency 2024

ND

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

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department will develop and implement a process whereby any provider who fails to respond to a request for records as part of an audit or program ...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department will develop and implement a process whereby any provider who fails to respond to a request for records as part of an audit or program integrity review by the established deadline will be subject to a corrective sanction process. This process will include a pre-payment review of claims for a designated period. Additionally, the department will continue to recover payments made on unsupported claims. Contact Person: Sarah Aker, Medicaid Executive Director Anticipated Completion Date: 12/31/2025

View Audit 346994 Questioned Costs: $1

Finding 529060 (2024-008)

Significant Deficiency 2024

State of North Dakota

ND

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

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services disagrees with the finding. The federal regulations do not explicitly mandate the separation of duties between employees conducting audits and those processing claims. While 42 CFR 456...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services disagrees with the finding. The federal regulations do not explicitly mandate the separation of duties between employees conducting audits and those processing claims. While 42 CFR 456.2 requires Medicaid agencies to implement a surveillance and utilization control program, it does not specifically require the segregation of these roles. The regulation promotes control measures but does not mandate a distinct separation of duties. Based on this, we do not support this recommendation, as it exceeds the requirements outlined in the applicable federal rules. HHS remains committed to maintaining strong internal controls and believe our current structure aligns with regulatory expectations. Contact Person: Sarah Aker, Medicaid Executive Director Krista Fremming, Assistant Director Anticipated Completion Date: N/A

View Audit 346994

Finding 529058 (2024-007)

Significant Deficiency 2024

State of North Dakota

ND

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

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department has controls in place to prevent errors. The target for this year’s Payment Error Rate Measurement (PERM) audit is 3.02%. Currently, ...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department has controls in place to prevent errors. The target for this year’s Payment Error Rate Measurement (PERM) audit is 3.02%. Currently, our error rate stands at 2.1%, which is below the CMS PERM target. The department will continue to recover the payments made on unsupported claims. Contact Person: Sarah Aker, Medicaid Executive Director Krista Fremming, Assistant Director Anticipated Completion Date: 06/30/2025

View Audit 346994 Questioned Costs: $1

Finding 529057 (2024-010)

Significant Deficiency 2024

State of North Dakota

ND

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

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. HHS has begun the process of recoupment and will work to receive full repayment, to date the balance remaining was $5,000 and a payment plan has been...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. HHS has begun the process of recoupment and will work to receive full repayment, to date the balance remaining was $5,000 and a payment plan has been sent up to recoup the remaining amount. The Accounts Payable team will collaborate with OMB to implement additional processes within Peoplesoft to verify payment information in the future. Currently, we are working to add display options in the Mass Voucher Approval screen to allow for tallying of the totals of vouchers in range. This addition will enhance the review step to ensure payments are consistent with Program totals for a secondary check before approval of payments are made. Contact Person: Karol Riedman, Assistant CFO Ann Scott, AP Accounting Manager Anticipated Completion Date: 06/30/2025

View Audit 346994 Questioned Costs: $1

Finding 529056 (2024-006)

Significant Deficiency 2024

State of North Dakota

ND

Questioned Costs Period of Performance Subrecipient Monitoring

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department will monitor expenses within the budget and grant period based on guidance from the federal agency to ensure that the date of expenditu...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. The department will monitor expenses within the budget and grant period based on guidance from the federal agency to ensure that the date of expenditures are not claimed before grant funds are received. Contact Person: Eric Haas, Assistant CFO Anticipated Completion Date: December 2024

View Audit 346994 Questioned Costs: $1

Finding 529055 (2024-005)

Significant Deficiency 2024

State of North Dakota

ND

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.343

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. To address this, the department will run quarterly reports from AWARE to identify any payments charged to the incorrect period of performance. Grant ...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. To address this, the department will run quarterly reports from AWARE to identify any payments charged to the incorrect period of performance. Grant guidance has been updated to ensure items with unique service dates are properly reviewed. Additionally, during the three-month liquidation period, a monthly review of all expenditures will be conducted to verify they are applied to the correct period of performance. These actions will strengthen oversight and ensure compliance with grant requirements. Contact Person: Eric Haas, Assistant CFO Anticipated Completion Date: December 2024

View Audit 346994 Questioned Costs: $1

Finding 529053 (2024-009)

Significant Deficiency 2024

State of North Dakota

ND

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.302 § 200.303

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. During review of audit found two overpayment errors as a result of outdated supporting documents. Refunds have been requested. HHS provides ongoing t...

Department of Health and Human Services Response/Corrective Action Plan The Department of Health and Human Services agrees with the recommendation. During review of audit found two overpayment errors as a result of outdated supporting documents. Refunds have been requested. HHS provides ongoing training with eligibility and supervisory staff regarding document and eligibility requirements with staff. HHS actively monitors application quality and provides ongoing quality control reviews ensuring consistent adherence to best practices. Contact Person: Jessica Thomasson, Executive Policy Director Anticipated Completion Date: October 2024

View Audit 346994 Questioned Costs: $1

Finding 529052 (2024-013)

Significant Deficiency 2024

State of North Dakota

ND

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

Department of Health and Human Services Response/Corrective Action Plan HHS agrees with the recommendation. During a period of high application volume, HHS temporarily bypassed its two-stage review process, assigning supervisors to review cases directly. The audit found no errors in eligibility du...

Department of Health and Human Services Response/Corrective Action Plan HHS agrees with the recommendation. During a period of high application volume, HHS temporarily bypassed its two-stage review process, assigning supervisors to review cases directly. The audit found no errors in eligibility during this time. To address this, HHS updated policies to document exceptions, including thresholds for initiating and ending them, ensuring transparency. Training sessions are being conducted to familiarize staff with these updates, and weekly monitoring of application volumes continues to anticipate surges. Contingency hiring plans and cross-training initiatives are in place to reduce future exceptions. Periodic reviews will ensure compliance, fostering a scalable, accountable process while maintaining high standards during peak periods. These measures ensure consistency and preparedness moving forward. Contact Person: Jessica Thomasson, Executive Policy Director Anticipated Completion Date: August 2024

View Audit 346994

Finding 529023 (2024-015)

Significant Deficiency 2024

State of North Dakota

ND

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Department of Public Instruction Response/Corrective Action Plan: We agree with the finding. The issue has already been corrected as stated in the finding. Contact Person: Jamie Mertz, CFO Anticipated Completion Date: The issue has already been corrected.

View Audit 346994 Questioned Costs: $1

Finding 528980 (2024-014)

Significant Deficiency 2024

State of North Dakota

ND

Subrecipient Monitoring Cash Management Matching / Level of Effort / Earmarking § 200.208 § 200.303 § 200.339

Department of Public Instruction Response/Corrective Action Plan: We agree with the issues identified. 1. NDDPI acknowledges the late reports in FSRS.gov from October 2022 to September 2023. As stated in the finding, the reports were initially reported, but according to the Helpdesk with FSRS.go...

Department of Public Instruction Response/Corrective Action Plan: We agree with the issues identified. 1. NDDPI acknowledges the late reports in FSRS.gov from October 2022 to September 2023. As stated in the finding, the reports were initially reported, but according to the Helpdesk with FSRS.gov, they required removal to re-submit using the corrected FAIN numbers. NDDPI administrators were not aware that the reports initially filed would be deleted from the records, versus the incorrect reports becoming labeled as inactive and saved for historical purposes. Kim Vega, Administrative Officer with NDDPI will review current archive processes and determine where changes may be needed. The FSRS website will be eliminated as the reporting application for FFATA in the Spring of 2025, and from that time forward, will be performed in the SAM.gov application. Currently, NDDPI administrators are participating in training and presentations for the test website and will continue to watch for any changes to administrative tasks. An introduction of the new website’s capabilities did address enhancing the feature for deleted reports as a part of the user’s tasks rather than the Helpdesk’s responsibility. NDDPI will continue to follow this development while in training for SAM.gov reporting. With the changes in application sites, the future enhancement in ND Foods will include an Application Programming Interface (API) for FFATA reporting. This API will provide the capability of real-time reporting, eliminate most manual tasks, increase report accuracy, and improve team member productivity and efficiency. The new website also mentions the zip code validation as an upgraded process. This process in the current system has been an intense time drain for staff members who enter FFATA by manual entry or batch upload, so improved functionality in this area is a much-needed upgrade. 2. NDDPI acknowledges the submission of the late report leading up to March 2024 as stated in item number 1. Reports for the meal claims were not reported in FSRS.gov until the FAIN numbers and programming were corrected in ND Foods, and a new Excel report was written with the corrections. Therefore, the report was not submitted within the required deadline. NDDPI Administrative officer worked with the Child Nutrition Administrative Staff Officer and NDIT programmers to correct the programming and process new reports for batch upload. 3. NDDPI acknowledges the missing reports for November and December 2023. During the transition from one claim year to the following, multiple reports must be run in ND Foods to complete the block FFATA reports. In 2023, NDDPI administrators were not aware of the overlap of claim years and how it would affect reporting, and therefore, only the current-year reports were processed. Currently, ND Foods has been upgraded to include an automated feature for FFATA reporting to include the final claims from the prior year and the new year’s claims in its reports for batch upload. Every effort was made to report both the old claim year and the new claim year in 2024. 4. NDDPI administrators have reviewed the reporting dates and the obligation date for claims in the CN block reporting, and we have agreed on the federal guidance which indicates the awards are obligated in advance will have the date of signature or acceptance at NDDPI, and the batch upload for payments made to an award will have the action or obligation date of the approval date for payment. This process will correct the reporting dates for claim payment processing (10.559, 10.555, 10.558, 10.556, 10.553) or reporting month for an obligated award (10.582) and its required obligation date. NDDPI staff members should be able to test and implement a programming change in our current reporting system in the next 2 months. If this change proves to be more intense than planned, we will wait on a quick fix until the upcoming interface upgrade with Sam.gov. We know the interfacing upgrade will require an even greater amount of time, energy, and money, and it will be a change we must complete; therefore, if the quick fix proves to be ineffective and time-consuming, the change in reporting will wait until the programming begins for the API Interface. Currently, federal officials are reporting the transfer between reporting sites will be ‘Spring of 2025’ but are not giving users a specific date. We have consolidated the coordination of FFATA reporting to a single individual rather than having each area do their own. We will prepare and implement procedures for the FFATA reporting. Contact Person: Jamie Mertz, CFO Anticipated Completion Date: June 30, 2025

View Audit 346994

Finding 528974 (2024-018)

Significant Deficiency 2024

State of North Dakota

ND

Reporting Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303 § 200.502

Office of Management and Budget Response/Corrective Action Plan: The Office of Management and Budget agrees with this finding. OMB agrees but will continue federal reporting based on the timing of reimbursement of expenditures to other state agencies for the duration of the SLFRF reporting perio...

Office of Management and Budget Response/Corrective Action Plan: The Office of Management and Budget agrees with this finding. OMB agrees but will continue federal reporting based on the timing of reimbursement of expenditures to other state agencies for the duration of the SLFRF reporting period. OMB will ensure all expenditures of SFLRF funding are accurately included in the reports based on the period of reimbursement. Because OMB is responsible for the state reporting under this program, it is necessary to maintain some level of control over these funds. Consequently, OMB manages the funds centrally and developed a process to reimburse agencies for their eligible expenditures once expenditures were incurred and agencies requested reimbursement. As a result, reimbursement from the state’s allocation of SLFRF moneys always occurs after the agency expenditure. Funds are included in the Federal report for the period in which reimbursement from the SLFRF occurs. In some cases, this results in the agency expenditure occurring in a period prior to the period covered under the quarterly SLFRF report in which the reimbursement is reported. To better track OMB expenditures of SLFRF moneys, which is a separate process from the reimbursement of other agencies, OMB will run specific expense reports for OMB agency expenditures to ensure all SLFRF expenses are reported in the proper period. Contact Person: Elizabeth Roger, Account Budget Specialist Anticipated Completion Date: December 2026

View Audit 346994

Finding 528949 (2024-004)

Significant Deficiency 2024

Galena City School District

AK

School Nutrition Programs Reporting Cash Management § 200.303

Finding 2024-004 Reporting – Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan This occurrence was due to a change in management and the error was corrected when it was identified. Since then, all the documentation was submitted within parameters of ...

Finding 2024-004 Reporting – Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan This occurrence was due to a change in management and the error was corrected when it was identified. Since then, all the documentation was submitted within parameters of the grant. Expected Completion Date 12/21/2023

View Audit 346942

Finding 528948 (2024-003)

Material Weakness 2024

Galena City School District

AK

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.313

Finding 2024-003 Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan The District acknowledges the finding regarding failure to retain source check documentation supporting student count certification for the Impact Aid program. In resp...

Finding 2024-003 Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan The District acknowledges the finding regarding failure to retain source check documentation supporting student count certification for the Impact Aid program. In response to this issue, which pertained to source check forms from FY22 that were subject to review when payment was made in FY24, we have already implemented corrective measures. Under the oversight of our Director of Federal Programs, the District established and implemented comprehensive records retention procedures compliant with 2 CFR 200.303, including clear documentation requirements for federally connected children, a centralized digital repository for all Impact Aid records, a verification checklist system, and staff training on proper documentation protocols. This implementation was completed in June 2024, ensuring all records are now maintained in accordance with federal uniform guidance requirements. Expected Completion Date 07/01/2024

View Audit 346942

Finding 528885 (2024-011)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

Guidance email was provided to program supervisors in February 2025, reiterating the requirement that all RESEA Checklists must be completed by staff and supervisors. Yearly file reviews – Bureau of Workforce Partnership and Operations (BWPO) is currently conducting case file reviews of the local o...

Guidance email was provided to program supervisors in February 2025, reiterating the requirement that all RESEA Checklists must be completed by staff and supervisors. Yearly file reviews – Bureau of Workforce Partnership and Operations (BWPO) is currently conducting case file reviews of the local offices. Once the review is completed, each area will get a results email with concerns and recommendations. These reviews started in September 2024 and will continue until they are completed. Anticipated completion is November 2025. Quarterly meetings were held for all local areas (2/4/25, 2/5/25 & 2/6/25). Next quarterly meetings will be held in May 2025. These meetings will reiterate the importance of following the RESEA process as detailed in the RESEA desk guide. Anticipated Completion Date: 11/30/2025 Contact Name: Dorraine Rauch, Division Chief

View Audit 346904

Finding 528884 (2024-010)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Eligibility § 200.303

L&I has taken the following steps to resolve the finding: - The system issue which caused the lack of denials was fixed in December 2024. - Maximum potential overpayment amount was estimated by getting a list of all those union hiring hall members since the launch of the new system and then removing...

L&I has taken the following steps to resolve the finding: - The system issue which caused the lack of denials was fixed in December 2024. - Maximum potential overpayment amount was estimated by getting a list of all those union hiring hall members since the launch of the new system and then removing the following from the list: - Those who registered for work. - Those exempt for other reasons. - Those denied benefits for other reasons. - Those with no payments for weeks beyond the 4th week of the claim. - The remaining individuals’ payments for the fifth week of the claim and later were totaled in January 2025: - 3,481 individuals - $22,597,596.92 - These amounts are described as “maximum” because only an individual review of each claim would reveal if the person was truly not properly registered and if weeks of benefits should be overpaid. - The Department is choosing to waive these individuals’ requirement to register based on UC law section 401(b)(6): The department may waive or alter the requirements of this subsection in cases or situations with respect to which the secretary finds that compliance with such requirements would be oppressive or which would be inconsistent with the purposes of this act. Since the individuals would currently be told of requirements they needed to meet in the past and, as a result, given debts to repay, this is oppressive in nature and inconsistent with the purpose behind the registration requirement. Anticipated Completion Date: Completed Contact Names: Stacy Walter, Management Analyst 2, Special Projects, Office of UC Service Centers; Rick Plesnarski, Management Supervisor, Special Projects Unit & Quality Assurance, Office of UC Service Centers

View Audit 346904 Questioned Costs: $1

Finding 528851 (2024-007)

Material Weakness 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Office of Income Maintenance (OIM) Bureau of Operations (BOO): BOO will take the following actions to address the finding: 1. All CAOs and district offices will be reminded of the EBT Coordinators’, alternates’, pinners’, and card makers’ responsibilities. The BOO will ensure users in the EBT Card ...

Office of Income Maintenance (OIM) Bureau of Operations (BOO): BOO will take the following actions to address the finding: 1. All CAOs and district offices will be reminded of the EBT Coordinators’, alternates’, pinners’, and card makers’ responsibilities. The BOO will ensure users in the EBT Card Tracking Database know their responsibilities and segregation of duties. 2. The BOO will ensure offices know EBT cards are only to be made during business hours. BOO will work with the EBT Project Office to update the OIM EBT Procedure Manual for clarification. This will occur by April 1, 2025. 3. All CAOs and district offices will be reminded to update the EBT card tracking database within 24 hours of an individual’s status change. Clarification will be sent to the Area Managers to distribute to staff. This will occur by April 1, 2025. 4. All EBT Coordinators will be reminded to review the updates/changes to the OIM EBT Procedure Manual quarterly. Anticipated Completion Date: 04/01/2025 Contact Name: Jeanette Coulston, Staff Assistant to Director of Bureau of Operations OIM Bureau of Program Support (BPS)/EBT Project Office: BPS will take the following actions to address the finding: 1. The EBT Project Office will provide clarification and make updates to the OIM EBT Procedure Manual, in the Staff Security Section, for removing individuals from the EBT card tracking database. The updates will include screenshots for easier comprehension. This is expected to be completed by April 1, 2025. 2. The EBT Project Office will make updates to the OIM EBT Procedure Manual, in the EBT Security for Over the Counter (OTC) Card Mailing Section, to include “CAOs should not print OTC EBT Cards outside of normal business hours”. This is expected to be completed by April 1, 2025. 3. The OIM EBT Procedure Manual is updated quarterly. An email notification is sent to all EBT Coordinators, via a distribution list, notifying them of the updates/changes. This is expected to be completed by April 1, 2025. Anticipated Completion Date: 04/01/2025 Contact Name: Tonya Holloway, Division Director OIM Bureau of Program Evaluation (BPE)/Division of Corrective Action (DCA): BPE will take the following actions to address the finding: The Bureau of Program Evaluation, Division of Corrective Action conducts EBT Card Security reviews at every CAO and District Office that issues EBT cards. These reviews are completed on a three-year rotation to ensure compliance in the execution of documented policies and procedures. When needed, BPE/DCA will adjust the review criteria to incorporate any procedural changes implemented in the OIM EBT Procedure Manual. Annually, BPE/DCA EBT Headquarters staff provide training to DCA Income Maintenance Examiners in both field offices, to ensure awareness of any policy or procedure changes, prior to the start of the EBT reviews. The current rotation schedule spans FFY 2025- FFY 2027. The new three-year schedule began October 2024. Anticipated Completion Date:Completed Contact Name: Amira S. Milikin, Division Director

View Audit 346904 Questioned Costs: $1

Finding 528827 (2024-003)

Material Weakness 2024

Frankton Lapel Community School Corporation

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

Information on the federal program : Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Nu...

Information on the federal program : Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Context : The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER II amount reported for the reports covering the FY22 time period ($230,281) did not agree to the underlying expenditure records ($4,290 for the period of July 1, 2021 through June 30, 2022). We also noted there was no documented, secondary review of the information in the annual data reports by someone other than the preparer. Contact Person Responsible for Corrective Action: Candace McDonald Contact Phone Number: 765-734-1261 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Director of Finance will review financial statements and ensure they agree to amounts reported on the annual data reports. Reviews will be documented with a signature. FTE documentation will be retained. Anticipated Completion Date: When the next report is due

View Audit 346885

Finding 528820 (2024-004)

Material Weakness 2024

Clinton Prairie School Corporation

IN

Internal Control / Segregation of Duties School Nutrition Programs Eligibility § 200.303

FINDING 2024-004 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or...

FINDING 2024-004 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Contact Person Responsible for Corrective Action: Contact Phone Number: • Jill Pollard, 765-654-4473, ext 401 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: • There will be dual control on all applications Anticipated Completion Date: • 12/31/2025

View Audit 346869

Finding 528817 (2024-003)

Material Weakness 2024

Clinton Prairie School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2024-003 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or...

FINDING 2024-003 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness Context: Crowe noted there was no review of all 35 timecards selected for testing in a sample of 40 payroll transactions. The other 5 sample payroll transactions for salaried employees were tested without error. Contact Person Responsible for Corrective Action: Contact Phone Number: • Linda Burkhalter, 765-659-1339, ext 113 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: • We will have dual control on all timesheets. Anticipated Completion Date: • 3/17/2025

View Audit 346869

Finding 528783 (2024-002)

Material Weakness 2024

Latin American Association, Inc.

GA

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

We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, a new policy was implemented that requires employees to record their time as a percentage across all grants in which they work. The employee records this allocation at least ...

We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, a new policy was implemented that requires employees to record their time as a percentage across all grants in which they work. The employee records this allocation at least weekly within a time keeping software system. Employees and supervisors are now required to review and acknowledge payroll allocations across grants by signing weekly timesheets. Timesheets will be retained and used as backup by the Grants Department when invoicing the Grantor for expense reimbursement. In addition, we have updated our Policy and Procedures Manual to reflect this policy. An additional policy was implemented in November 2024 requiring one Accounting staffer and one Grant staffer review employee timecards versus invoices prior to submission. The Policy and Procedures Manual has been updated to reflect this policy. Responsible Parties: Kimberly Yoo, CFO Whitney Gillis, Director of RD Mary Guzman, Accounting Supervisor Date Corrected: November 2024

View Audit 346843

Finding 528773 (2024-002)

Material Weakness 2024

Saline County, Nebraska

NE

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

County will implement procedures to ensure reporting is completed correctly.

View Audit 346806

Finding 528728 (2024-002)

Significant Deficiency 2024

Fort Worth Transportation Authority

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2024-002: Matching Major Federal Program: Federal Transit Cluster Compliance Requirements: Allowable Costs and Cost Principles, Cash Management, Matching Response: Concur: An inaccurate reimbursement rate was applied causing overpayment of $613,075. Due to the inaccuracy of the percentage ra...

Finding 2024-002: Matching Major Federal Program: Federal Transit Cluster Compliance Requirements: Allowable Costs and Cost Principles, Cash Management, Matching Response: Concur: An inaccurate reimbursement rate was applied causing overpayment of $613,075. Due to the inaccuracy of the percentage rate applied in this drawdown, Trinity Metro will actively reinforce its internal control processes to ensure detailed reviews related to cost reimbursement rates are accurately identified monthly by those who are authorized to process drawdowns. Implementation will take place immediately. Steps that will be taken include: 􀁸 Dual-Approval Process for Reimbursement Requests: Both the Grants Department and Accounting will confirm the accuracy of the reimbursement rate before submission. 􀁸 Grant Agreement Review Process: Both the Grants Department and Accounting will jointly review grant agreements before submitting reimbursement requests to ensure that the correct rate if applied. Date of Completion: This action plan will go into effect immediately. Person Responsible to Ensure Completion: Contact Person: Greg Jordan, Chief Financial Officer Contact Person: Eva Williams, Director of Budget and Grants, Finance

View Audit 346790 Questioned Costs: $1

Finding 528726 (2024-004)

Material Weakness 2024

Evansdale Municipal Housing Authority

IA

HUD Housing Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

2024-004 Activities Allowed - Management Agrees with Finding. EHMA will formally adopt an entity wide budget for the Fiscal Year beginning July 1, 2025 to include the Housing Choice Voucher (HCV) Program and revenue for reimbursement for shared expenses with Green Roof Properties. Additionally, the...

2024-004 Activities Allowed - Management Agrees with Finding. EHMA will formally adopt an entity wide budget for the Fiscal Year beginning July 1, 2025 to include the Housing Choice Voucher (HCV) Program and revenue for reimbursement for shared expenses with Green Roof Properties. Additionally, the Board of Directors for Green Roof Properties will adopt a budget for the upcoming FY. EMHA will also work with the fee accountant to incorporate the adopted budget and report on variances into the monthly financial reports they produce. Furthermore, the Board will be provided a breakdown of the allocation of expenses to each program when presenting disbursements for their approval monthly.

View Audit 346789

Finding 528724 (2024-003)

Material Weakness 2024

North Miami Community Schools

IN

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Context: For the two projects sampled for Davis-Bacon requirements, the School Corporation did not obtain the weekly payroll reports certifications from the company that performed renovations on the School Corporation. Therefore, no review was performed to ensure that pay rates complied with the fed...

Context: For the two projects sampled for Davis-Bacon requirements, the School Corporation did not obtain the weekly payroll reports certifications from the company that performed renovations on the School Corporation. Therefore, no review was performed to ensure that pay rates complied with the federal wage rate requirements. Additionally, the School Corporation did not have contracts with the company that included the clause for the federal wage rate requirements. The amount disbursed and reported on the SEFA during the audit period is $447,034 and the labor portion was not determinable by the School Corporation. Contact Person Responsible for Corrective Action: Serena Francis, Business Manager Contact Phone Number: 765-985-3891 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: If NMCS enters into contractual agreements where Davis-Bacon rules will apply we make arrangements before the contract is signed to meet all of the necessary requirements. Anticipated Completion Date: 3/1/2025

View Audit 346755

Finding 528722 (2024-001)

Significant Deficiency 2024

Froedtert Health, Inc. and Affiliates

WI

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

Corrective Actions Relating to Federal Awards: Finding 2024 001 Lack of review and approval of Time and Effort Reporting Corrective Actions Manual processes will be ...

Corrective Actions Relating to Federal Awards: Finding 2024 001 Lack of review and approval of Time and Effort Reporting Corrective Actions Manual processes will be reinforced regarding time and effort reporting (T/E) and Operations (Ops) will be instructed to hold each drawdown until all processes are completed and approved by the Grant Program Manager. Grant Program Manager will also conduct more frequent internal monitoring of completeness of records, and create an e-learning for all team members involved in the grant process regarding the steps that need to be followed. The Froedtert ThedaCare Health (FTCH) compliance team has created a proposal to implement a Grant Management Software solution. The software solution will have mechanisms for facilitating automated and streamlined processes to support time and effort documentation requirements. Specific actions to be taken include: Party Responsible Laurie Moore, Grant Program Manager Corrective Action Reinforce T/E and implement hold practice with each Ops owner expensing salaries Anticipated Completion Date April 1, 2025 Party Responsible Laurie Moore, Grant Program Manager Corrective Action Increase internal monitoring frequency for grants expensing salaries Anticipated Completion Date Beginning April 15, 2025 and ongoing thereafter Party Responsible Laurie Moore, Grant Program Manager Corrective Action Create e-learning Anticipated Completion Date Create Learning: May 1, 2025 Implementation: June 1, 2025 (If not able to do e-learn, will publish PowerPoint)

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Corrective Action Plans

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