Corrective Action Plans

Finding 558461 (2024-008)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

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

Finding: The Employment Security Department did not have adequate internal controls to ensure compliance with federal requirements to annually certify that employer tax credits reported under the Federal Unemployment Tax Act are matched against employer contributions paid under the Unemployment Ins...

Finding: The Employment Security Department did not have adequate internal controls to ensure compliance with federal requirements to annually certify that employer tax credits reported under the Federal Unemployment Tax Act are matched against employer contributions paid under the Unemployment Insurance program. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department is committed to ensuring that the required reports for the Federal Unemployment Tax Act are properly reviewed and in compliance with federal requirements. The Department has a process in place for a secondary review of the employer tax credit reports prior to certification. The two exceptions identified in the audit were isolated incidents where both the preparer and reviewer missed one of the 50 lines on the two reports being reviewed. The Department will ensure management adequately reviews employer account reconciliations performed by staff to ensure the required number of accounts are reviewed for all reports prior to submission. Completion Date: February 2025 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

View Audit 355165

Finding 558460 (2024-007)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with federal requirements to conduct case reviews for the Benefit Accuracy Measurement program of the Unemployment Insurance program in a timely manner. Questioned Costs: Assistance Listin...

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with federal requirements to conduct case reviews for the Benefit Accuracy Measurement program of the Unemployment Insurance program in a timely manner. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department is committed to ensuring our Benefit Accuracy Measurement (BAM) program complies with federal regulations. Historically, the BAM unit has been challenged to maintain full levels of staffing. Staff turnover, lengthy training requirements, and unique skill sets make these positions difficult to maintain. The Department has implemented changes to position descriptions which have resulted in the hiring and retention of qualified staff. As a result, the unit has improved its case sampling timelines by implementing regular case reviews to ensure the 60-day, 90-day, and 120-day timelines are met. Additionally, the Department, in collaboration with the U.S. Department of Labor (USDOL), developed a State Quality Service Plan (SQSP) which includes metrics to improve program outcomes. The team has implemented additional internal communication to follow up on cases which are approaching the 120-day timeline. Although the 120-day timeline is not an improvement measure listed on the SQSP, the Department will continue to work with USDOL to implement guidance and processes to meet the 120-day requirement. The conditions noted in this finding were previously reported in findings 2023-009, 2022-006, 2021-005, and 2020-011. Completion Date: January 2025 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

View Audit 355165

Finding 558459 (2024-006)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Finding: The Office of Superintendent of Public Instruction did not have internal controls over and did not comply with requirements to verify single audits were completed for all subrecipients of the Child and Adult Care Program. Questioned Costs: Assistance Listing # 10.558 Amount $0 Sta...

Finding: The Office of Superintendent of Public Instruction did not have internal controls over and did not comply with requirements to verify single audits were completed for all subrecipients of the Child and Adult Care Program. Questioned Costs: Assistance Listing # 10.558 Amount $0 Status: Corrective action in progress Corrective Action: The Office has implemented internal controls to ensure all subrecipients requiring a single audit are identified and to follow up on any program-related findings that require a management decision. Procedures are also updated to maintain the subrecipient audit tracking log. The Office will implement a training plan for the Child Nutrition Services fiscal team, which includes cross training and completing the State Auditor’s Office subrecipient monitoring training. The Office will follow up with the subrecipient identified in the audit to ensure it obtains its required single audit. The conditions noted in this finding were previously reported in finding 2023-004. Completion Date: Estimated June 2025 Agency Contact: Debbie Libra Fiscal & Claims Supervisor PO Box 47200 Olympia, WA 98504-7200 (564) 233-8620 Debbie.libra@k12.wa.us

View Audit 355165

Finding 558340 (2024-002)

Material Weakness 2024

Box Butte General Hospital

NE

Cash Management Material Weakness Matching / Level of Effort / Earmarking

Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in Februar...

Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in February 2024 that took the hospital offline from processing claims. These two events had a negative and material impact on overall operating results as additional accounts receivable allowances for both contractual adjustments and bad debts were necessary at June 30, 2024. The negative impact on overall operations resulted in the Hospital not meeting the required 1.5 debt service coverage ratio and having less than 90 days of cash on hand at June 30, 2024. The Hospital did receive a waiver for from the USDA regarding not meeting these loan covenants for fiscal year 2024. Views of responsible officials and planned corrective actions The implementation of the new electronic health records created a delay in operational workflow processes which required vendor modifications and corrections to the system. This delayed submitting insurance claims for reimbursement continued throughout fiscal year 2024. Operations have now stabilized and the debt service coverage ratio is expected to be in compliance in fiscal year 2025. Hospital management notified its USDA representatives and received a waiver from the required 1.5 debt service coverage ratio and required 90 days of cash on hand for the period ended June 30, 2024. Anticipated completion date Ongoing

View Audit 355131

Finding 558257 (2024-049)

Material Weakness 2024

State of Rhode Island

RI

Questioned Costs Eligibility Internal Control / Segregation of Duties

DHS continues its prior actions of training addressing eligibility, standing agenda on meetings, and quarterly meetings. At this time, DHS has completed the solicitation to hire a contractor to identify problematic processes, through the Business Processing Excellence Reengineering project. (BPER). ...

DHS continues its prior actions of training addressing eligibility, standing agenda on meetings, and quarterly meetings. At this time, DHS has completed the solicitation to hire a contractor to identify problematic processes, through the Business Processing Excellence Reengineering project. (BPER). The scope of work includes evaluating the eligibility to determine the deficiencies and to propose solutions. Anticipated Completion Date: Ongoing Contact Person: Donna Rook, Administrator, Family and Adult Services, Department of Human Servicesdonna.m.rook@dhs.ri.gov

View Audit 355126 Questioned Costs: $1

Finding 558041 (2024-030)

Material Weakness 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303

Formal internal control processes have been established for the Federal Funding Accountability and Transparency Act (FFATA) reporting, FFATA Preparation and Submission, 17-102. Additionally, FFATA review and approval has been delineated appropriately between the Director of Finance, Grants Manager, ...

Formal internal control processes have been established for the Federal Funding Accountability and Transparency Act (FFATA) reporting, FFATA Preparation and Submission, 17-102. Additionally, FFATA review and approval has been delineated appropriately between the Director of Finance, Grants Manager, and Federal Funds Accountant.

View Audit 354902

Finding 557720 (2024-027)

Material Weakness 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

DCH will develop a reconciliation process between members denied within Georgia Gateway and members removed within GAMMIS. DHS will provide training as outlined within the current contract to address changes and updates to Medicaid policy and the Georgia Gateway system.

View Audit 354902 Questioned Costs: $1

Finding 557416 (2024-025)

Material Weakness 2024

State of Georgia/state Accounting Office-Ein Noted

GA

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

The Office of Procurement Services (OPS) has dedicated staff that have attended Federal Funding Accountability and Transparency Act (FFATA) training and webinars. In addition, the same dedicated staff will verify that all federal grants with sub-recipients are properly reported. Beginning in FY 202...

The Office of Procurement Services (OPS) has dedicated staff that have attended Federal Funding Accountability and Transparency Act (FFATA) training and webinars. In addition, the same dedicated staff will verify that all federal grants with sub-recipients are properly reported. Beginning in FY 2025 (September 2024), the OPS has required programs that receive federal funding to email a PDF copy of the monthly FFATA report submitted in the FFATA Subaward Reporting System (FSRS) to the designated staff no later than the fifth of each month. Currently, the FY25 FFATA Reporting is up to date and the Office of Procurement Services will continue to review and adjust the process through FY 2025 (June 30, 2025).

View Audit 354902

Finding 556721 (2024-035)

Material Weakness 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Reporting Special Tests & Provisions Subrecipient Monitoring § 200.303

GDOL Response: GDOL acknowledges this is a repeated finding from previous years, therefore the Department concurs with this finding and offers the following response. GDOL now freezes the overpayment data at the end of every month so we can conduct periodic reconciliation of the overpayment recor...

GDOL Response: GDOL acknowledges this is a repeated finding from previous years, therefore the Department concurs with this finding and offers the following response. GDOL now freezes the overpayment data at the end of every month so we can conduct periodic reconciliation of the overpayment records. This will allow discrepancies to be identified faster and resolved before the deadline to submit the report for the specified period. GDOL consults with USDOL’s national 227 reporting specialists on an ongoing basis to work towards a reconciliation of previously submitted reports. Federal regulations require an actual person to review and establish fraudulent overpayments. Due to the volume of claims and the number of cross matches to be performed on all state and federal pandemic programs, it requires multiple GDOL staffing levels to manually review all cross matches, requiring increased levels of state and federal funding. A cross match cannot be assumed to be an overpayment. GDOL must investigate cross matches and provide due process to all parties. GDOL developed an aggressive plan to complete all crossmatches. As of June 2024, GDOL was caught up and resume our regular crossmatch schedule. The current unemployment system is aged and distressed. GDOL’s limited technology resources will hinder our ability to update our current system to perform reconciliation between the multiple tools used to perform different functions. Therefore, we acknowledge that this finding may persist until a system-wide resolution is implemented in the new modernized UI system. The Department has a significant number of pending and potential overpayment investigations that may result in either a non-fraud or fraud determination. We are utilizing merit and time-limited staff to maximize productivity by conducting fact-finding interviews, assessing case details, creating overpayments in the system, and making overpayment determinations. The statutes provide that an overpayment be established up to four years after such occurrence, act, or omission. Additionally, GDOL has procured a vendor to build and implement a modernized UI system slated to be launched in 2026. We will continue to utilize available resources to investigate and establish overpayments in the legacy system as quickly as possible and will continue to do so within the program parameters in the new system. Throughout CY 2024, GDOL participated in quarterly meetings with United States Department of Labor (USDOL) and other regional states to discuss fraud, overpayment issues and best practices used. These meetings will continue in CY2025. Summary: GDOL greatly appreciates the feedback and recommendations and will ensure these and USDOL’s recommendations are incorporated into our new modernized system which is expected to be implemented in the Spring 2026.

View Audit 354902

Finding 556719 (2024-033)

Material Weakness 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility § 200.303 § 200.53

GDOL Response: GDOL acknowledges this is a repeated finding from previous years and is partially resolved, therefore the Department concurs with this finding and offers the following response. GDOL’s limited technology resources and funding will hinder our ability to update our current system to s...

GDOL Response: GDOL acknowledges this is a repeated finding from previous years and is partially resolved, therefore the Department concurs with this finding and offers the following response. GDOL’s limited technology resources and funding will hinder our ability to update our current system to satisfy the state audit’s recommendation. Therefore, we acknowledge that this finding will persist until a system-wide resolution is implemented in the new modernized UI system. GDOL will include a self-certification and dual certification process for employer-filed claims in the new solution. GDOL will also secure data analytic tools to aid GDOL staff with the identification of potential improper or fraudulent Payments, which will include payments linked to employer filed claims.

View Audit 354902

Finding 556718 (2024-032)

Material Weakness 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.53

GDOL Response: GDOL acknowledges this is a repeated finding from previous years and is partially resolved, therefore the Department concurs with this finding and offers the following response. GDOL’s current UI Information Technology (IT) system was developed in 1982 using mainframe “legacy’ te...

GDOL Response: GDOL acknowledges this is a repeated finding from previous years and is partially resolved, therefore the Department concurs with this finding and offers the following response. GDOL’s current UI Information Technology (IT) system was developed in 1982 using mainframe “legacy’ technology. Due to the system’s age and other limitations, many automated processes and corrections cannot be fixed and/or easily implemented. As such, many processes must be handled manually by staff. This includes reviewing all the Pandemic Unemployment Assistance (PUA) proof documents submitted to determine the validity and eligibility for each PUA claim. Based on the volume of workload and staff limitations, GDOL has been unable to quickly complete this manual review to correct the finding. It is anticipated this manual review will continue throughout the FY25 audit review period. The modernized UI system will include controls over eligibility determination for current and future unemployment programs. Employer-Filed Claims (EFC) are submitted by employers on behalf of the claimant. The employer is responsible for attesting to the employment status and weekly earnings of the claimant for the EFC submitted. An affidavit certifying that the employer has obtained earnings from other employment as well as other requirements must be completed before EFCs can be entered or uploaded. Claimants for which EFCs submitted are considered to be still attached to the employer and are exempt from the requirement to register for employment services per Georgia Employment Security Law Rule 300-2-4-.02. Such individuals are not required to be nor certify on a weekly basis to be able, available and actively seeking work. We recognize the state auditor's recommendations to add the self-certification. However, the current unemployment system is aged and distressed. GDOL’s limited technology resources will hinder our ability to update our current system to satisfy the state audit’s recommendation. Therefore, we acknowledge that this finding will persist until a system-wide resolution is implemented in the new modernized UI system. GDOL will include a self-certification process for employer-filed claims in the new solution. GDOL has procured a vendor to build and implement a modernized UI system. We are also pursuing data analytics tools to expedite the identification and detection of fraudulent activities. These tools will also be incorporated into the modernized solution. Summary: GDOL greatly appreciates the feedback and recommendations and will ensure they are incorporated into the new UI modernized system which is planned to be implemented in Spring 2026.

View Audit 354902 Questioned Costs: $1

Finding 556248 (2024-014)

Material Weakness 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Subrecipient Monitoring Allowable Costs / Cost Principles School Nutrition Programs § 200.303

We have prepared procedures for Federal Funding Accountability and Transparency Act (FFATA) reporting specifically for USDA. We shifted a current GaDOE accounting manager's job duties to include assisting the Assistant Director of Accounting with overall FFATA reporting duties. The addition of an ex...

We have prepared procedures for Federal Funding Accountability and Transparency Act (FFATA) reporting specifically for USDA. We shifted a current GaDOE accounting manager's job duties to include assisting the Assistant Director of Accounting with overall FFATA reporting duties. The addition of an experienced staff member to assist with FFATA data gathering, reconciling, and reporting will allow for the Assistant Director of Accounting to focus on completing the more complex FFATA Reporting for USDA in a timely manner.

View Audit 354902

Finding 556198 (2024-003)

Material Weakness 2024

Puerto Rico Industrial Development Company

PR

Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.512

VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report...

VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report in conformity with US GAAP and federal regulations. Management will improve accounting and financial reporting policies and procedures to include the timely issuance of the financial statement and the uniform guidance report. IMPLEMENTATION DATE March 31, 2026 RESPONSIBLE PERSON Paola Rosario CPA, CFO

View Audit 354899

Finding 556161 (2024-003)

Material Weakness 2024

Lone Pine Unified School District

CA

Questioned Costs Equipment & Real Property Management Internal Control / Segregation of Duties

The purchase of all equipment will follow the pre-approval process stated in the Title 2, Code of Federal Regulations, Part 200, Subpart E, Section 200.439 and implement procedures to address the deficiencies currently identified.

View Audit 354835 Questioned Costs: $1

Finding 555761 (2024-002)

Material Weakness 2024

Human Response Network

CA

Material Weakness Reporting

Explanation and Corrective Action Taken: The audit for the Year Ended June 30, 2021 was completed in June 2023 which has caused a rippling effect for subsequent audits to be filed late. The Fiscal Officer that was responsible for the June 30, 2021 audit did not prepare or provide the necessary finan...

Explanation and Corrective Action Taken: The audit for the Year Ended June 30, 2021 was completed in June 2023 which has caused a rippling effect for subsequent audits to be filed late. The Fiscal Officer that was responsible for the June 30, 2021 audit did not prepare or provide the necessary financial information to the Auditors. That Fiscal Officer resigned in March 2022 and the position remained vacant until August 1st, 2022. In August 2022, the preceding Fiscal Officer was rehired. During their prior employment from February 2013 until March 2021 there were no audit findings. In addition to the Fiscal Officer position being vacant for five months, there was a new fiscal coordinator position created and the fiscal assistant position had gone through 3 staff members in less than three years. There are no staff at Human Response Network (HRN) with accounting education or experience except for the Fiscal Officer and fiscal department of three. The Fiscal Officer who was re-hired in August 2022 completed the 6/30/2021 audit, submitted May 4, 2023, the 6/30/2022 audit, submitted July 9, 2024, and the 6/30/2023 audit, submitted January 23, 2025. The 6/30/2024 audit is currently in progress and nearly finished. All efforts to submit it to the Federal Clearinghouse by 3/31/2025 were made, however we will miss the deadline by approximately 2 weeks. Human Response Network agrees that monthly reconciliations of all general ledger and balance sheet accounts should be performed timely and accurately. Staff continue to receive internal and external training and mentoring from experienced staff members. The Fiscal Procedures will be reviewed and updated to strengthen internal controls and weaknesses in processes or controls within 90 days of the audit submission.

View Audit 354424

Finding 555664 (2024-003)

Material Weakness 2024

Magnolia School District

CA

Material Weakness Reporting Internal Control / Segregation of Duties

We agree with the recommendation and moving forward all federal expenditures and full-time equivalent positions are reported accurately on the ESSER annual and quarterly reports, and that supporting documentation is maintained to support the amounts reported.

View Audit 354273

Finding 555570 (2024-007)

Material Weakness 2024

Lincoln Street Housing, Inc.

CA

HUD Housing Programs Eligibility Material Weakness

Finding 2024-007 The June 2023 voucher was not correct when initially submitted. HCEB has attempted over the past 18 months to correct the June 2023 voucher, working closely with our Yardi support and HUD-SF team. Once the June 2023 voucher is paid, July 2023 and subsequent vouchers will be matched ...

Finding 2024-007 The June 2023 voucher was not correct when initially submitted. HCEB has attempted over the past 18 months to correct the June 2023 voucher, working closely with our Yardi support and HUD-SF team. Once the June 2023 voucher is paid, July 2023 and subsequent vouchers will be matched to Yardi records and submitted to TRACS processing.

View Audit 354066

Finding 555554 (2024-003)

Material Weakness 2024

San Bernardino City Unified School District

CA

Allowable Costs / Cost Principles Reporting Subrecipient Monitoring

When this matter was brought to the District's attention it was too late to adjust for FY 2023-2024 but the District took steps to ensure all ESSER Funds impacted were fully expended and the indirect charges were ultimately balanced out.

View Audit 354064

Finding 555356 (2024-003)

Material Weakness 2024

Micro Entrerprise Services of Oregon

OR

Allowable Costs / Cost Principles Material Weakness

Finding # 2024-003 Type: Material weakness over allowable costs A.L. 14.218 U.S. Department of Housing and Urban Development A.L. 21.027 U.S. Department of Treasury Material Weakness Invoices submitted to funding agencies did not have documented review and approval for 8 of 13 invoices reviewed....

Finding # 2024-003 Type: Material weakness over allowable costs A.L. 14.218 U.S. Department of Housing and Urban Development A.L. 21.027 U.S. Department of Treasury Material Weakness Invoices submitted to funding agencies did not have documented review and approval for 8 of 13 invoices reviewed. Corrective Action: As of February 2025, we have implemented a process to document the review and approval of invoices by the grants manager. Anticipated Completion Date February 28, 2025

View Audit 353993

Finding 555350 (2024-002)

Material Weakness 2024

Micro Entrerprise Services of Oregon

OR

Allowable Costs / Cost Principles Material Weakness

Finding # 2024-002 Type: Material weakness Type: Material noncompliance over allowable costs A.L. 14.218 U.S. Department of Housing and Urban Development A.L. 21.027 U.S. Department of Treasury Material Weakness/Material Noncompliance Personnel expenses charged to federal awards must be supporte...

Finding # 2024-002 Type: Material weakness Type: Material noncompliance over allowable costs A.L. 14.218 U.S. Department of Housing and Urban Development A.L. 21.027 U.S. Department of Treasury Material Weakness/Material Noncompliance Personnel expenses charged to federal awards must be supported records that reflect the time worked charged to the award. The Organization charged personnel expenses based on approved budgeted amounts in the award agreement for 12 of 64 items tested. Corrective Action: We will implement additional training with employees on tracking time as well as develop an improved timesheet process. We are also in the process of implementing a new payroll system to ensure integration with the accounting system. Anticipated Completion Date July 1, 2025

View Audit 353993

Finding 555345 (2024-002)

Material Weakness 2024

Newhall School District

CA

Subrecipient Monitoring Material Weakness Reporting

Corrective Action Plan and Views of Responsible Officials Views of Responsible Officials The District acknowledges the audit finding regarding insufficient retention of financial records supporting the annual ESSER expenditure reports submitted to the California Department of Education. We understan...

Corrective Action Plan and Views of Responsible Officials Views of Responsible Officials The District acknowledges the audit finding regarding insufficient retention of financial records supporting the annual ESSER expenditure reports submitted to the California Department of Education. We understand that maintaining accurate and accessible documentation is essential to federal compliance under Title 2, Code of Federal Regulations (CFR) §200.334. The District takes full responsibility for this oversight and is taking immediate steps to strengthen its internal controls and documentation practices. Corrective Action Plan 1. Reason for the Finding: This issue arose due to high turnover in the position responsible for federal reporting. As a result, institutional knowledge and documentation practices were disrupted, making it difficult to locate supporting financial records for the annual ESSER expenditure report. While the quarterly reports submitted throughout the year were accurate and properly supported, the annual report was not fully aligned with available documentation due to incomplete record retention during the staffing transitions. 2. Actions to be Taken to Correct the Issue: Centralized Document Management System: The District will implement a centralized, secure electronic document management system (e.g., Google Drive, SharePoint, or a financial records database) specifically for tracking and retaining federal program documentation. All financial records supporting ESSER and similar federal grants will be stored here and categorized by funding source, fiscal year, and reporting period. Standard Operating Procedure (SOP): A formal SOP for federal grants management will be created and distributed to all relevant departments. This will include clear guidelines for documentation, record retention timelines, and roles/responsibilities for financial reconciliation and audit readiness. Staff Training: District staff responsible for federal program management and reporting will be trained on the new SOP, federal compliance regulations (including CFR §200.334), and the use of the document management system. Refresher trainings will be conducted annually or as needed. Pre-Submission Review: A dual review process will be instituted where both the Business Services and Federal Programs teams confirm the availability and accuracy of supporting documentation before any reports are submitted to oversight agencies. 3. Timeline for Implementation: All corrective actions will be in place within 90 days. The centralized document storage system and SOPs will be finalized and rolled out within 60 days. Staff training will be completed within the following 30 days. Immediate measures to retain ESSER documentation have already been initiated.

View Audit 353992

Finding 555193 (2024-001)

Material Weakness 2024

The Guidance Center, Inc.

AZ

Reporting Material Weakness

Item: 2024-001 Assitance Listing Number: 93.959 Programs: Block Grants for Substance Abuse Prevention, Treatment and Recovery Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Care 1st Compliance Reqauirements: Reporting Criteria of Specific Requireme...

Item: 2024-001 Assitance Listing Number: 93.959 Programs: Block Grants for Substance Abuse Prevention, Treatment and Recovery Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Care 1st Compliance Reqauirements: Reporting Criteria of Specific Requirement: In accordance with the grant agreement, the Organization is required to submit quarterly reports during the grant period which include qualifying costs incurred under the grant award. Condition: A required quarterly report submitted to the granting agency included inaccurate reporting of the qualifying expenditures. Additionally, for all four quarterly reports there was no evidence of management review or approval of the reports prior to submission to the funder. Name of Contact Person: Michael Kuzmin, Chief Financial Officer Phone Number: (928) 714-6478 Anticipated Completion Date: March 31, 2025 Views of Responsible Officials and Corrective Action: Management agrees with the finding and will implement additional controls to ensure expense information included in the quarterly reports in reviewed and approved prior to submission. Management will ensure this additional process includes clearly documenting the review and approval.

View Audit 353812

Finding 555173 (2024-004)

Material Weakness 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director ...

Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limted to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555171 (2024-002)

Material Weakness 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Identifying Number: 2024-002 Finding: Material Weakness: Allowable Costs/Cost Principles Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were not incurred until 2025. Corrective Actions Taken or Planned: The Director of the Office...

Identifying Number: 2024-002 Finding: Material Weakness: Allowable Costs/Cost Principles Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were not incurred until 2025. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Correcting the gaps between invoicing processes and collecting the Departments/AP proof of payment b. Returning overpayments, if applicable c. Implementing organizational changes such as updated policies and/or procedures d. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices duing the Grant management processes. Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Create processes in which we will adopt verification procedures for invoices and collections. - Create/update Standard Operating Procedures (SOPs) - Provide our team with updated training material (working practice guidelines - WPGs), so they have clear expectations and understand our compliance mechanism. - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555144 (2024-004)

Material Weakness 2024

Grape Community Hospital, Inc. D/b/a George C. Grape Community Hospital

IA

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing: #10.766 Compliance Requirement: Special Tests and Provisions Criteria: The Hospital must establish and maintain effective internal control over federal a...

Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing: #10.766 Compliance Requirement: Special Tests and Provisions Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the Hospital to maintain a debt service reserve fund as bookkeeping accounts or as separate bank accounts. Condition: Funds that represented the debt service reserve fund were commingled with an existing operating cash account. Planned Corrective Action: Management agrees with the funding and will deposit the required debt service reserve funds in either a separate bank account or general ledger account. Planned Completion Date: September 30, 2025 Person Responsible: Doug Brandt, Chief Financial Officer

View Audit 353739

Corrective Action Plans

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