Corrective Action Plans

Finding 389343 (2023-004)

Material Weakness 2023

DE

Subrecipient Monitoring Material Weakness Reporting § 200.303

MATERIAL WEAKNESS 2023-004 Community Development Block Grant/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County subsequently report the subawards not reported in FSRS. We further recommend the County strengthen controls and procedures to ensure that all r...

MATERIAL WEAKNESS 2023-004 Community Development Block Grant/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County subsequently report the subawards not reported in FSRS. We further recommend the County strengthen controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Community Services was made aware of the FFATA issue at the end of FY22. The Department developed and executed a Standard Operating Procedure (SOP) to ensure all awards over $30,000 were submitted to the FSRS system within the required time. In FY23 we entered the FY22 and FY23 sub-recipient awards in FSRS. In FY23 there were expenses for sub-recipient awards that were issued in FY20 and FY21, which was identified by CLA. The Department will modify our SOP to require all sub-recipient awards be entered regardless of the fiscal year they were awarded; this ensures accurate and up-to-date reporting. Name(s) of the contact person(s) responsible for corrective action: Mike Kapa Planned completion date for corrective action plan: June 30, 2024

View Audit 300342

Finding 389338 (2023-003)

Material Weakness 2023

Columbiana Metropolitan Housing Authority

OH

Questioned Costs HUD Housing Programs Eligibility

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Vouchers programs and will implement internal control procedures that will ensure compliance with federal regulations. Melissa Bead...

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Vouchers programs and will implement internal control procedures that will ensure compliance with federal regulations. Melissa Beadle, Deputy Director, will be responsible for implementing this corrective action by June 30, 2024. CMHA is aware that the HAB/MRI software does not store waitlist reports by date processed and since then, CMHA has been saving Excel files of the waitlist reports. The applicants that were selected for the audit were applicants that had preference points. All applicants with preference points were contacted at the same time to be informed that they were eligible for a voucher. The CMHA waitlists were ran by preference points and time/date of application. Once those applicants were pulled the waitlist was not saved to Excel. The preference point list was then sorted alphabetically for sign in purposes and tracking of applicant documentation. This is the list that was provided to the auditor.

View Audit 300341 Questioned Costs: $1

Finding 389337 (2023-002)

Material Weakness 2023

Columbiana Metropolitan Housing Authority

OH

Questioned Costs HUD Housing Programs Material Weakness

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Vouchers programs and will implement internal control procedures that will ensure compliance with federal regulations. Michael McDo...

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Vouchers programs and will implement internal control procedures that will ensure compliance with federal regulations. Michael McDougle, HCV Manager, will be responsible to implement this corrective action by June 30, 2024. CMHA has been working diligently over the past IO months to implement this corrective action with the current two CMHA employee inspectors that are following up on the life and safety 24 hour inspections and also the 30 day follow ups. When landlords have informed CMHA that they are unable to find contractors to complement the maintenance failed items, CMHA is making a note on the inspection forms and tenant file as landlords inform CM HA that they are in need of additional time. The inspection reports under this audit were completed by the contractor, Inspection Group and have since then been corrected. To date, all of the failed inspections have been reinspected and passed.

View Audit 300341 Questioned Costs: $1

Finding 389336 (2023-001)

Material Weakness 2023

Columbiana Metropolitan Housing Authority

OH

Questioned Costs HUD Housing Programs Material Weakness

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Voucher programs and will implement internal control procedures that will ensure compliance with federal regulations. Michael McDou...

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Voucher programs and will implement internal control procedures that will ensure compliance with federal regulations. Michael McDougle, HCV Manager, will be responsible to implement this corrective action by June 30, 2024. CMHA has been working diligently over the past IO months to correct the inspection process that was not completed by the contracted inspectors through Inspection Group. Tenants were under the impression that they were not required to have inspections if someone was sick in their household, as previously waived during the pandemic. The HCV tenants have since been informed with each month's recertification mailing that they are required under HUD regulations to have an annual inspection. CMHA has also trained and assigned two HCV staff to become inspectors and have a process in place where one employee completes the annual inspections and the other employee follows up on the reinspection as needed. If inspections are not completed by time of recertification, the HAP payment is held. To date, annual inspections have been completed by CMHA staff.

View Audit 300341 Questioned Costs: $1

Finding 389332 (2023-002)

Material Weakness 2023

The Thresholds and Affiliated Organizations

IL

Reporting Material Weakness

Condition: An award passed through IDHS was not initially classified with the correct assistance listing number on the Schedule of Expenditures of Federal Awards (SEFA) by the Agency. The incorrect ALN was identified during audit procedures and corrected by the Agency. Planned Corrective Action: Thr...

Condition: An award passed through IDHS was not initially classified with the correct assistance listing number on the Schedule of Expenditures of Federal Awards (SEFA) by the Agency. The incorrect ALN was identified during audit procedures and corrected by the Agency. Planned Corrective Action: Thresholds will have a colleague outside of the Grants team (Controller or SVP for Finance) review future SEFAs. We will pay particular attention to ensure all expenditures are shown with the correct ALN, dollar amounts, and other fields. Contact person responsible for corrective action: Al Shoreibah, Chief Financial Officer Anticipated Completion Date: April 1, 2024

View Audit 300324

Finding 389331 (2023-001)

Material Weakness 2023

The Thresholds and Affiliated Organizations

IL

Material Weakness Reporting

Condition: The Organization's controls in place for reporting submissions did not identify Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to the lost revenue calculations. The Period 4 reporting submission for...

Condition: The Organization's controls in place for reporting submissions did not identify Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to the lost revenue calculations. The Period 4 reporting submission for lost revenue did not follow the acceptable options outlined by HHS. Additionally, the Period 2 reporting submission, completed in the previous year, did not follow the acceptable options. Planned Corrective Action: Thresholds will have a second individual (Controller or SVP for Finance) review future award applications that are one-time or unusual in nature. We will pay particular attention to review the terms carefully so that Thresholds does not misunderstand things (such as the acceptable options, as in this case). Contact person responsible for corrective action: Al Shoreibah, Chief Financial Officer Anticipated Completion Date: April 1, 2024.

View Audit 300324

Finding 389300 (2023-002)

Material Weakness 2023

Rockport Housing Authority

MA

Questioned Costs HUD Housing Programs Special Tests & Provisions

RHA started using Affordable Housing to provide Rent Reasonableness reports. In addition, once the HCV program started to be managed by NHA, they use Rent O Meter to provide Rent Reasonableness Reports and NHA staff will enter those numbers into PHA web to maintain as a part of the annual renewal pr...

RHA started using Affordable Housing to provide Rent Reasonableness reports. In addition, once the HCV program started to be managed by NHA, they use Rent O Meter to provide Rent Reasonableness Reports and NHA staff will enter those numbers into PHA web to maintain as a part of the annual renewal process or when a rent increase is requested by the landlord. In addition, a checklist was developed to make sure that all items are collected as necessary and entered into the PHA web system (housing management system).

View Audit 300304 Questioned Costs: $1

Finding 389299 (2023-001)

Material Weakness 2023

Rockport Housing Authority

MA

HUD Housing Programs Eligibility Material Weakness

The housing authority had instances of income, asset or medical miscalculation or insufficient verification and (1) instance of incorrect payment standard. Rockport Housing Authority (RHA) contracted with Newburyport Housing Authority (NHA) to manage the Section 8 program. They will be calculating i...

The housing authority had instances of income, asset or medical miscalculation or insufficient verification and (1) instance of incorrect payment standard. Rockport Housing Authority (RHA) contracted with Newburyport Housing Authority (NHA) to manage the Section 8 program. They will be calculating income, assets and/or medical expenses based on HUD regulation. NHA is staffed with an experienced Section 8 Coordinator. In addition, NHA uses Rent O Meter to provide Rent Reasonableness Reporting that will then be entered into PHA web as a method of record .

View Audit 300304

Finding 388585 (2023-004)

Material Weakness 2023

Siouxland Human Investment Partnership, Inc.

IA

Cash Management Material Weakness Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.305

Federal Agency Name: Department of Education Pass-through Entity: State of Iowa Department of Education Federal Financial Assistance Listing #84.287 Program Name: Twenty-First Century Community Learning Centers Program Cash Management Material Weakness in Internal Control over Compliance Finding S...

Federal Agency Name: Department of Education Pass-through Entity: State of Iowa Department of Education Federal Financial Assistance Listing #84.287 Program Name: Twenty-First Century Community Learning Centers Program Cash Management Material Weakness in Internal Control over Compliance Finding Summary: No support could be provided for the third quarter draw requests to substantiate a secondary level of review was completed prior to submission of the draws. Documentation to support the review of draw requests prior to submission was not retained during the transition period in the Finance Director role. Corrective Action Plan: SHIP had a one-month period of transition in 2023 in which there was no one in the Finance Director role. The Executive Director took over those duties and also contracted for higher level review and approval from a third-party accounting firm during the transitional period. All draws were reviewed, approved and even supported by the Executive Director and the contractors. SHIP did provide current auditors with the time tracking from the contracted accounting firm that they did review the 3rd quarter report, the report was just not officially signed off on. Staff requesting the draw forgot to get one approval signature for quarter three, all others were signed. Moving forward, SHIP will re-train staff to ensure all draws are signed off on. Responsible Individuals: Mindy Baylor - SHIP Finance Director Anticipated Completion Date: September 2023

View Audit 300275

Finding 388569 (2023-002)

Material Weakness 2023

Mid-Atlantc Christian University

NC

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

2023-002 Initial Fiscal Year End, 2023 Summary of Finding- During the 2023 audit, it was noted that the University's Gramm-Leach-Bliley Act Policy did not fully address all of the requirements as described by 16 CFR 314.4. In addition, the application of the comprehensive information security progra...

2023-002 Initial Fiscal Year End, 2023 Summary of Finding- During the 2023 audit, it was noted that the University's Gramm-Leach-Bliley Act Policy did not fully address all of the requirements as described by 16 CFR 314.4. In addition, the application of the comprehensive information security program was not effectively administered by the University for the 2023 year. Name and Title of Responsible Contact Person(s)- Sara Shepherd, Vice President for Finance and Nicole Umphlett, Financial Aid Administrator Corrective Action Plan Summary-The University has updated its Gramm-Leach-Bliley Act Policy to be in accordance with the requirements, and we have also put in place adequate controls and practices to ensure that the policy is monitored effectively. Anticipated Completion Date- February 1, 2024

View Audit 300264

Finding 388562 (2023-010)

Material Weakness 2023

Crothersville Community Schools

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328 § 200.329

Finding 2023-010 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and one ESSER III report, for a total of five reports. A single employee prepared and submitted...

Finding 2023-010 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and one ESSER III report, for a total of five reports. A single employee prepared and submitted each annual data report without a review or oversight process in place to prevent, or detect and correct, errors. All five reports were selected for testing, two of which were not supported by the School Corporation's records. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Another individual will start to review the information entered into the required ESSER reports prior to submission and supporting documentation will be retained. Anticipated Completion Date: April 1, 2024

View Audit 300250

Finding 388559 (2023-008)

Material Weakness 2023

Crothersville Community Schools

IN

Internal Control / Segregation of Duties Special Tests & Provisions Material Weakness § 200.207 § 200.303

FINDING 2023-008 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Assessment System Security Summary of Finding: The School Corporation had not adopted a test security policy. Although training had been provided to staff on an annual basis, the School Co...

FINDING 2023-008 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Assessment System Security Summary of Finding: The School Corporation had not adopted a test security policy. Although training had been provided to staff on an annual basis, the School Corporation had not established a system of internal controls to ensure monitoring of Assessment System Security occurred and was adequate. There were no INDIANA STATE BOARD OF ACCOUNTS 40 documented internal controls in place to ensure all individuals that should have received training did receive training. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The corporation will implement a Test Security Policy. Currently, the board is on the first reading and the second reading will occur on April 15, 2024. Superintendent is now the Title I director and is keeping the training certifications on file and retained for future audits. Anticipated Completion Date: April 15, 2024

View Audit 300250

Finding 388557 (2023-007)

Material Weakness 2023

Crothersville Community Schools

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Special Tests & Provisions § 200.303 § 200.334

FINDING 2023-007 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Summary of Finding: The School Corporation did not have effective internal controls in place to ensure the correct reporting requirements fo...

FINDING 2023-007 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Summary of Finding: The School Corporation did not have effective internal controls in place to ensure the correct reporting requirements for the High School Graduation Rate were being followed and that documentation was retained for audit. There was no tangible evidence of a process in place over the Annual Report Card/High School Graduation Rate to ensure that mobility codes were entered correctly. Of the 11 students tested, documentation was not presented for 9 students that were removed from the high school graduation cohort. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. A reminder will go to the High School guidance counselor, secretary, and principal about getting withdrawal forms from students and placing the form in their permanent records. Anticipated Completion Date: April 1, 2024

View Audit 300250

Finding 388555 (2023-006)

Material Weakness 2023

Crothersville Community Schools

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-006 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: During the audit period the School Corporation submitted three final expenditure reports. The final expenditure reports were completed and submitted by the Treasurer without an oversight or...

FINDING 2023-006 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: During the audit period the School Corporation submitted three final expenditure reports. The final expenditure reports were completed and submitted by the Treasurer without an oversight or review process in place to prevent, or detect and correct, errors. In addition, the final expenditure report for the Title I School Improvement for program year 2021, due December 30, 2021, was submitted March 7, 2024. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. INDIANA STATE BOARD OF ACCOUNTS 39 Description of Corrective Action Plan: The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Another individual will start reviewing the final expenditure reports prior to submission to IDOE. Anticipated Completion Date: April 1, 2024

View Audit 300250

Finding 388551 (2023-004)

Material Weakness 2023

Crothersville Community Schools

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.334 § 200.77 § 200.78

FINDING 2023-004 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Summary of Finding: One person was primarily responsible for compiling and uploading student data, including poverty status for Real Time reports. There was no additional review or verification being done to...

FINDING 2023-004 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Summary of Finding: One person was primarily responsible for compiling and uploading student data, including poverty status for Real Time reports. There was no additional review or verification being done to ensure that the numbers being pre-populated on the grant applications were correct. There was no internal control in place, such as an oversight, review or approval process to ensure eligibility was properly determined. There was no October 1 Real Time report presented for audit for either fiscal year 2020-2021 or 2021- 2022, which would have been used to pull in enrollment and poverty information for the 2021-2022 and 2022-2023 grants, respectively. Therefore, we were unable to verify if the amounts reported in the grant application were correct. Additionally, we were unable to verify if the correct socioeconomic status was properly reported for any of the students. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Superintendent will retain the Real Time reports and other supporting documentation. Superintendent will also start verifying the numbers pre-populated on the grant application to ensure correct reporting. Another person will start reviewing the application prior to submission to IDOE. Anticipated Completion Date: April 1, 2024

View Audit 300250

Finding 388549 (2023-003)

Material Weakness 2023

Crothersville Community Schools

IN

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

FINDING 2023-003 Finding Subject: Title I Grants to Local Educational Agencies – Internal Controls Summary of Finding: The School Corporation did not have a properly developed internal control process over payroll transactions to ensure expenditures were allowed and in conformance with the cost prin...

FINDING 2023-003 Finding Subject: Title I Grants to Local Educational Agencies – Internal Controls Summary of Finding: The School Corporation did not have a properly developed internal control process over payroll transactions to ensure expenditures were allowed and in conformance with the cost principles. The Program Administrator reviewed a report attached to program reimbursement requests which showed the total amount paid from each fund and account; however, a detailed payroll report was not reviewed which would have identified the employee and related payroll benefits being paid from the grant fund. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 37 The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Superintendent will start to review the detailed payroll report posted to the Title I funds to match to the reimbursement request. Anticipated Completion Date: April 1, 2024

View Audit 300250

Finding 388529 (2023-001)

Material Weakness 2023

Consolidated North County Levee District

MO

Material Weakness Reporting Internal Control / Segregation of Duties

2023-001 Material Weakness in Internal Control over financial reporting Criteria: Management is responsible for establishing and maintaining internal controls in the financial reporting system and for the fair presentation of the financial position, results of operations, and disclosures in th...

2023-001 Material Weakness in Internal Control over financial reporting Criteria: Management is responsible for establishing and maintaining internal controls in the financial reporting system and for the fair presentation of the financial position, results of operations, and disclosures in the financial statements, in conformity with the cash basis of accounting. Condition: The District does not have an individual that has the ability to evaluate the completeness and accuracy of the statements presented in accordance with the cash basis of accounting. Cause: The District only has a volunteer board and has elected to outsource the preparation of the annual financial statements. Effect: The District must rely on its external auditors to determine adherence to applicable cash basis of accounting. CORRECTIVE ACTION PLAN RESPONSE: Management concurs with this finding and will continue to evaluate the risk of outsourcing financial statement preparation versus the cost of staffing at this level. Anticipated completion date: 6/30/24 Responsible party: Kevin Machens, President Please contact Kevin Machens at 314-750-2519 with questions regarding this plan.

View Audit 300231

Finding 388437 (2023-012)

Material Weakness 2023

State of Hawaii, Department of Accounting and General Services

HI

Subrecipient Monitoring Material Weakness Reporting

2023‐012 – Reporting (Material Weakness) State Department of Labor and Industrial Relations AL Numbers and Program Title: 17.258 – WIOA Adult Program 17.259 – WIOA Youth Activities 17.278 – WIOA Dislocated Worker Formula Grant (WIOA Cluster) Condition Reporting required by Section 2, Full Disclosure...

2023‐012 – Reporting (Material Weakness) State Department of Labor and Industrial Relations AL Numbers and Program Title: 17.258 – WIOA Adult Program 17.259 – WIOA Youth Activities 17.278 – WIOA Dislocated Worker Formula Grant (WIOA Cluster) Condition Reporting required by Section 2, Full Disclosure of Entities Receiving Federal Funding, of the FFATA was not completed. Current Status of Corrective Action Plan Concur. -Due to changes in program personnel, there was miscommunication between the parties responsible for filing the FFATA reports. -Previous ASO left abruptly in 2023 with limited to no cross‐training. Other positions vacated in 2023 as well. The ASO and Accountant VI vacancies were filled on December 1, 2023 and February 1, 2024, respectively. -The ASO will come up with a checklist of pertinent reports that are due for WIOA programs including FFTA reporting and have the responsible staffs (Accountant and Supervisor) report to ASO Officer and WDD Administrator monthly for verification. Person Responsible Lynn Araki‐Regan, Administrative Services Officer Anticipated Date of Completion March 15, 2024

View Audit 300162

Finding 388432 (2023-010)

Material Weakness 2023

State of Hawaii, Department of Accounting and General Services

HI

Special Tests & Provisions Material Weakness

Finding No. 2023‐010 – Special Tests and Provisions (Material Weakness) State Department of Labor and Industrial Relations AL Number: 17.225 Program Title: Unemployment Insurance Condition Both and/or either the minimum number of cases and timeliness percentages for paid and denied claims including ...

Finding No. 2023‐010 – Special Tests and Provisions (Material Weakness) State Department of Labor and Industrial Relations AL Number: 17.225 Program Title: Unemployment Insurance Condition Both and/or either the minimum number of cases and timeliness percentages for paid and denied claims including monetary, separation, and nonseparation, were not met. Current Status of Corrective Action Plan Concur. -The BAM unit was short staffed an investigator from March 2022. The vacancy was filled on January 17, 2023. -The number of paid and denied claims were increased and the BAM supervisor was assigned denied cases. -The unit anticipates to meet the minimum number of 480 paid and 450 denied cases effective FY 23‐24 which began in July 2023. -The unit has made great strides and is currently meeting the denied timeliness requirements. -The unit has brought on an experienced adjudicator to fill a vacancy and learn BAM methodology. He is in the probationary period and is expected to continue to progress to the level where he will be able to function independently on simple to difficult and complex cases. The unit has worked cohesively to assist colleagues with investigative tasks. The TPS individual contributes to this effort by assisting with the assembly of new case files for the BAM investigators. This collective effort allows the unit to make progress to our goals. The BAM supervisor continues to help and monitor case completion and timeliness to ensure the unit works toward achieving the BAM requirements. Person Responsible Sheryl Maligro, UI Program Supervisor Anticipated Date of Completion June 2025

View Audit 300162

Finding 388425 (2023-001)

Material Weakness 2023

Christus Health

TX

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

Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...

Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2023 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.

View Audit 300159 Questioned Costs: $1

Finding 388380 (2023-003)

Material Weakness 2023

County of Los Angeles

CA

Subrecipient Monitoring Reporting Material Weakness § 200.303

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Acute Communicable Disease Controls (ACDC) agrees with the finding and recommendation. ACDC staff will monitor subawards and submit the required FFATA reports in the FFATA system upon execution date of the ...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Acute Communicable Disease Controls (ACDC) agrees with the finding and recommendation. ACDC staff will monitor subawards and submit the required FFATA reports in the FFATA system upon execution date of the amendment, but no later than the following month it was executed. This includes keeping monitoring logs of all contract amendments and modifications that are subject to FFATA reporting requirements. 3. Anticipated implementation date: March 1, 2024

View Audit 300135

Finding 388378 (2023-004)

Material Weakness 2023

County of Los Angeles

CA

Subrecipient Monitoring Reporting Material Weakness § 200.303

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Emergency Preparedness Response Program (EPRD) agrees with the finding and recommendation. EPRD staff will send the subrecipient/contractor the FFATA reporting notice, which includes a request for the fiv...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Emergency Preparedness Response Program (EPRD) agrees with the finding and recommendation. EPRD staff will send the subrecipient/contractor the FFATA reporting notice, which includes a request for the five most highly compensated officers at the same time the contract is sent to the subrecipient/contractor for signature. This will assist EPRD with tracking the reporting notice because once the subrecipient/contractor returns the signed contract, they will also return the FFATA reporting notice. Once staff receives the executed contract from DPH’s Contracts and Grants, the FFATA reporting system will be updated accordingly and a screenshot showing the date/time the report was submitted will be kept on file. 3. Anticipated implementation date: July 1, 2024

View Audit 300135

Finding 388358 (2023-005)

Material Weakness 2023

County of Los Angeles

CA

Subrecipient Monitoring Reporting Material Weakness § 200.303

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Division of HIV and STD Programs (DHSP) agrees with the finding and recommendation. DHSP will institute a new procedure that 1) notifies subaward recipients within 30 days of the effective date of the sub...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Division of HIV and STD Programs (DHSP) agrees with the finding and recommendation. DHSP will institute a new procedure that 1) notifies subaward recipients within 30 days of the effective date of the subaward execution or modification of relevant federal award information and 2) uploads federal subaward information to FFATA within 30 days of the effective date of the subaward execution or modification of relevant federal award information. These notifications will happen for all subawards that meet the threshold for FFATA reporting. DHSP understands that these notifications may precede the full execution of a new contract or subaward. 3. Anticipated implementation date: July 1, 2024

View Audit 300135

Finding 388349 (2023-007)

Material Weakness 2023

Department of Education, State of Hawaii

HI

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

2023-007 Special Tests and Provisions – Material Weakness View of Responsible Officials Management agrees with the findings and recommendations. Corrective Action Plan The audit finding was due in large part to a vacancy in the Department ESSER grant support position that arose in the first qua...

2023-007 Special Tests and Provisions – Material Weakness View of Responsible Officials Management agrees with the findings and recommendations. Corrective Action Plan The audit finding was due in large part to a vacancy in the Department ESSER grant support position that arose in the first quarter of the fiscal year, which contributed to the breakdown in construction project tracking. The Department hired a replacement for this grant support position in the second quarter of the fiscal year, and during the third quarter hired a second grant support position to ensure enhanced support capacity and continuity. These two individuals continue to comprise the ESSER Grant Management Office (team) and in the fourth quarter of the fiscal year initiated a process to document school and complex area use of ESSER funds for construction purposes. The team held a department-wide informational webinar in partnership with the Department’s Office of Facilities and Operations on May 22, 2023. The webinar agenda included the newly implemented pre-approval construction application process and federal requirements pursuant to Title 2, Section 200, Appendix II, of the Code of Federal Regulations (CFR). The team will continue to work with the Department’s Complex Area Staff to reiterate the award requirements and examine construction-related contracts over $2,000 to verify compliance with the award requirements. Contact Person: Brian Hallett Assistant Superintendent and CFO Office of Fiscal Services Anticipated Completion Date: June 30, 2024

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Finding 388343 (2023-002)

Material Weakness 2023

Department of Education, State of Hawaii

HI

Subrecipient Monitoring Material Weakness Reporting

2023-002 Reporting – Material Weakness View of Responsible Officials Administration agrees with the findings and recommendations. Corrective Action Plan The Office of Monitoring and Compliance (MAC) will provide training to recipients when funds are allocated within the Department. The Policy, ...

2023-002 Reporting – Material Weakness View of Responsible Officials Administration agrees with the findings and recommendations. Corrective Action Plan The Office of Monitoring and Compliance (MAC) will provide training to recipients when funds are allocated within the Department. The Policy, Innovation, Planning and Evaluation Branch (PIPE) will communicate with the Office of Fiscal Services and MAC on a semi-annual basis to start the reporting process on December 1 and June 1 of each year to meet the January 31 and July 31 respective deadlines. Additionally, PIPE has identified a dedicated staff member who will spearhead the administration of this grant to ensure that any changes in the reporting requirements as defined in the OIA Cooperative Agreement will be quickly identified and followed. Contact Persons: Ken Kakesako, Director Policy, Innovation, Planning and Evaluation Branch Office of Strategy Innovation and Performance Jacy Yamamoto, Interim Director Office of Monitoring and Compliance Office of the Deputy Superintendent Anticipated Completion Date: June 1, 2024

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Corrective Action Plans

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