Corrective Action Plans

Finding No. 2023-001

Corrective Action Plan

Name of the contact person responsible for corrective action

Gena Wingfield, Chief Financial Officer

Corrective action planned

During FY23 Arkansas Children’s implemented an automated tool that allows us to monitor and audit general IT controls going forward over logical access to the relevant systems. We have also strengthened our controls around provisioning and deprovisioning through formalization of our policies around privileged access and have implemented continuous auditing of sensitive roles.

As the automated controls were not in place during the full fiscal year, and therefore not tested during the audit, in FY24 Arkansas Children’s implemented temporary manual controls and processes. These controls support the review and approval of expenditures monthly to verify that they are allowable, incurred within the designated period of performance and incurred prior to reimbursement.

Anticipated completion date

2024-01-31 00:00:00

If the client does not agree with the audit findings or believes corrective action is not required, include an explanation and specific reasons

Agree with Finding No. 2023-001

The reference numbers the auditors assigned to the audit findings in the schedule of findings and questioned costs

Finding Number: 2023-001 – Period of Performance Planned Corrective Action: The item in question was a deposit for an event that took place in August 2023. It was made in June 2023. While the $24k payment was a valid payment within the grant terms, it was inadvertently recorded as an expense item in our 2023 schedule of expenditures of federal awards instead of as a prepaid asset. Upon discovery we implemented new procedures whereby payments made at year end will be subjected to an additional review to ensure they are recorded in the proper period. Person Responsible: Stephen Mack, Chief Financial Officer Expected Completion Date: Immediately

The Department will review its procedures and internal controls and update as necessary to ensure that expenditures are incurred within the allowable period of performance for respective awards. It should be noted that during the period of performance for which this audit was conducted there were a large number of personnel changes and shifts. The position that was responsible for the majority of these duties retired in January 2024. We proactively hired for her replacement a year before she retired. Over the course of the year our replacement took over more and more duties. In the process of this replacement, we have completed a tremendous amount of evaluation of our assigned duties, processes, workflow, training, and documentation. Not only in this role, but we are also undergoing a division and business unit wide analysis of our internal controls and workflow. It should also be noted that the UI admin funds are considered ‘formula funds’ from the US DOL. We are expected to run this program year-round with no gaps in service or performance. The funding that we receive from US DOL is based on an antiquated formula that breaks down the amount that is budgeted by Congress between 52 state and territories. We generally do not receive enough funding for the entire year. Also, with the recent trend of Congress to utilize the tool of the Continuing Resolution our funding is often ambiguous until most of the program year is over. We have at times seen our funding cut once a budget had been passed by Congress even though there was only about 3 months left in the program year. We are still expected to run this program and ‘find other sources of funding’. This does make the adherence to the period of performance challenging. However, as we evaluate our internal controls and procedures over the coming months, we will make note of every opportunity to strengthen this function to ensure that all charges applied to program funds are relevant, within the period of performance of the award, and are correctly reviewed and signed. Cameron Wood, UI Director, Cameron.Wood@vermont.gov Scheduled Completion Date of Corrective Action Plan: August 31, 2024

Contact person responsible for corrective action: University Registrar Corrective action: Sacred Heart University implemented a comprehensive corrective action plan in collaboration with the following key stakeholders: Sacred Heart University’s enterprise resource provider (ERP), Ellucian; the Registrar’s Office; and Sacred Heart University’s Department of Information Technology (IT). Sacred Heart University acknowledges the erroneous reporting of graduation effective dates for two students, wherein the effective start date of their first graduate course mistakenly overrode their previously reported correct graduation date. The University took decisive action to address the inaccuracies identified within a summer 2023 enrollment submission to National Student Clearinghouse for Branch 80 and Branch 81. Sacred Heart University conducted a thorough investigation with Ellucian Support to identify the source of these errors. The investigation resulted in a determination by Ellucian Support that the reporting error was caused by a software bug within its software platform, Ellucian Colleague. Ellucian developed a patch, released in October 2023, to rectify the issue. Implementation of this patch by the Sacred Heart University Information Technology department is scheduled for March 2024. Proposed completion date: March 31, 2024

Finding Number: 2023-002 Condition: SOMC Medical Care Foundation, Inc. (MCF) received $1.28M of ARP funding during period 4. As the recipient entity, MCF used the ARP funding in accordance with the terms and conditions, however the reporting on the use of MCF's ARP distributions was not properly completed. The parent company, Southern Ohio Medical Center, completed a consolidated period 4 report, which is appropriate based on the reporting requirements, however the expenses that were reported for the use of the $1.28M received by MCF were expenses of the parent company, not expenses of MCF. Planned Corrective Action: The Management of Southern Ohio Medical Center (SOMC) and its subsidiaries are committed to complying with all terms, conditions, and reporting requirements related to funds received. Management will carefully read and follow all notices relating to reporting requirements and terms and conditions for each type of future funds awarded, paying particular attention to requirements as they pertain to Parent and Subsidiary reporting. In addition, SOMC will ensure that any and all updated guidance provided after the receipt of funds are reviewed and included in the application of used funds. Although SOMC incorrectly reported the use funds received for the subsidiary MCF on the consolidated period 4 report, it is important to note that the ARP funds were used and applied to more than $1.3m of lost revenue during the expense and lost revenue period. SOMC Management cannot amend the period 4 report to reflect this, but Management has updated the detailed internal records identifying the use of funds by applying $1.28m of MCF lost revenue to use of funds for the appropriate periods. Contact person responsible for corrective action: Kara Plummer, CFO Anticipated Completion Date: 3/31/2024

An automated reporting process of salaries through our payroll provider (ADP) has been established to eliminate the manual data entry of payroll amounts. This will eliminate the opportunity for errors in manual salary entries.

Federal Agency Name: Department of Homeland Security & Emergency Management passed through State of Iowa department of Homeland Security and Emergency Management Assistance Listing Number: 97.3036, 4642DRIAP00000501 Program Name: Disaster Grants – Public Assistance Finding Summary: The Cooperative did not have any formally documented review and approval over the material and transportation costs claimed for reimbursement under the program. Corrective Action Plan: The Cooperative will document the review and approval of expenses for transportation and material that we are already doing. This will include initials and e-mails documenting the review process that was completed. For transportation the person reviewing the transportation logs with the payroll logs will initial the transportation logs. The person tying the transportation logs to the computer system and the vehicle’s actual ending mileage will also initial the transportation logs. For material transactions, a summary of transactions for the month will go to the appropriate department supervisor to sign off on those transactions. The person approving the transaction will depend on the department. Responsible Individuals: Department Supervisors who have inventory, Jaylen Heinz - Accountant, Kari Rubel - Accountant and other accountants. Anticipation Completion date: March 2024

Finding 2023-001 Period of Performance - AL 84.027 IDEA-B Criteria: IDEA Funding reports are to be submitted quarterly with appropriate documentation on how the funds were expended to the Allegheny Intermediate Unit. Condition: During the audit, it was noted that Gateway School District did not report for the IDEA fund quarterly. Cause: Gateway School District Business Manager did not realize that these quarterly reports needed to be submitted for the IDEA funds to Allegheny Intermediate Unit. Effect: By not realizing these quarterly reports needed to be submitted, Gateway School District may stop receiving funding for IDEA. Questioned Costs: The amount of questioned costs, if any, is undeterminable. Recommendation: Gateway School District should be submitting quarterly reports to the Allegheny Intermediate Unit's website. Management Response: Management will be submitting the quarterly report to the Allegheny Intermediate Unit's website, and submitted for the fiscal year 2022-2023 the full amount for the year in December 2023. Anticipate Completion Date: Immediate

FINDING 2023-002 Information on the federal program: Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listings Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (or Other Identifying Numbers): 19611-022-PN01, 20611-022-PN01, 21611-022-PN01, 22611-022-PN01, 22611-022-ARP, 23611-022-PN01, 20619-022-PN01, 21619-022-PN01, 22619-022-PN01, 22619-022-ARP, 23619-022-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Audit Finding: Material Weakness, Qualified Opinion Condition: The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The Cooperative had not designed or implemented adequate policies or procedures to determine that grant expenditures were for the excess costs of providing special education and related services to children with disabilities, were in conformance with the applicable cost principles and were obligated during the award period of performance. There was no documented oversight, review, or approval process in place at the Cooperative to ensure expenditures were allowable, conformed with cost principles and were incurred during the period of performance. Context: The School Corporation is a member of the Greene-Sullivan Special Education Cooperative (Cooperative). During fiscal year 2021-2022 and 2022-2023, the Cooperative operated the special education programs and spent the federal money on behalf of all its members.  As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The Cooperative had not designed or implemented adequate policies or procedures to determine that grant expenditures were for the excess costs of providing special education and related services to children with disabilities, were in conformance with the applicable cost principles and were obligated during the award period of performance. There was no documented oversight, review, or approval process in place at the Cooperative to ensure expenditures were allowable, conformed with cost principles and were incurred during the period of performance. The lack of internal controls was a systemic issue throughout the audit period. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action: 1 – All invoices, as well as receipts, will be documented upon receipt by the Director of Special Education at Greene Sullivan Special Education Cooperative. After this takes place, The Director of Finance at Greene Sullivan Special Education Cooperative will then create vouchers and receipts accordingly. Prior to submission, the Director of Special Education of Greene Sullivan Special Education Cooperative will verify all documents for accuracy. The Superintendent and Treasurer of Southwest School Corporation will review the documentation for the Cooperative at lease semi-annually. Responsible party and timeline for completion: Chris Stitzle, Superintendent – April 1, 2024

2023-016. Underlying Accounting Data Does Not Support CRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB has reviewed its master CRF expenditure file and reconciled all reported CRF expenditures to FINET transactions. The reconciliation accounted for original expenditure transactions, CRF expenditures that were booked when agencies are reimbursed for eligible transactions, and FEMA reimbursements for expenditures charged to the CRF. GOPB made final updates to the September 31, 2023, CRF quarterly report that was submitted on October 10, 2023. Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592 Anticipated Correction Date: Completed October 10, 2023

2023-015. Obligation of CRF Funds Not Completed Within Proper Timeframe State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB will save copies of the Treasury Department guidance documents and the September 2022 email from the Treasury Office of the Inspector General that it used to determine that it could update the December 31, 2022 quarterly CRF report to include additional benefit payments from the Unemployment Compensation Fund made between March 1, 2020 and December 31, 2021. GOPB will also save copies of financial reports and other documentation that demonstrates the total costs incurred from the Unemployment Compensation Fund during that time frame did not exceed total deposits into the fund from the CRF, SLFRF, or other sources. Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592 Anticipated Correction Date: March 31, 2024

Name of contact person: Rita Huck Corrective Action: The 21st Century Community Learning Centers grant director was told by the Office of Public Instruction that the District could pay for expenditures that were incurred in July, 2022 for a summer program that was held until the middle of July, 2022. These payments were made from the FY 2022 grant that was scheduled to end June 30, 2022. We have discussed how and when obligations and expenditures will be handled going forward. Proposed Completion Date: Immediately.

Corrective Action Plan: The University has implemented significant process and validation enhancements in this area. The operational manual was revised to include detailed procedures. Management manually reviewed CIP codes for all programs and updated system records as appropriate on October 12, 2023. Management conducted two subsequent reviews on January 3, 2024, and January 5, 2024, to ensure compliance with the requirements. Implementation Dates: Revisions to operational manual, October 12, 2023. Updates to system records, October 12, 2023. Management review for continued compliance, January 3, 2024 and January 5, 2024. Responsible Persons: Blanca E. Guerra, Ph.D., University Registrar Brandy Simpkins Piner, M.P.A., Senior Associate Registrar

Corrective action plan: HHSC completed the correction of the rate prior to year-end close on August 25, 2023. General Ledger Cost Allocation Team will work with CFO Operations Support to develop a query to identify journal transactions that post in the CAPPS Financials general ledger module before the project start date. This query will be run monthly and any exceptions will be corrected. An additional review of the new fiscal year payroll projects will be performed by both Budget and the General Ledger Chartfield teams as part of annual fiscal year close coordination. Implementation date: August 31, 2024 Responsible person: Heather Nevill, Director, Fund Management