Corrective Action Plans

Finding 498106 (2020-011)

Significant Deficiency 2023

The Center for Black Women's Wellness, Inc.

GA

Questioned Costs Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303 § 200.320

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal polic...

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to include procurement and implemented a procedure for ensuring compliance with obtaining required bids, etc. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

View Audit 320765 Questioned Costs: $1

Finding 498104 (2020-009)

Material Weakness 2023

The Center for Black Women's Wellness, Inc.

GA

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303 § 200.308 § 200.309 § 200.403

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal polic...

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

View Audit 320765 Questioned Costs: $1

Finding 498102 (2020-007)

Significant Deficiency 2023

The Center for Black Women's Wellness, Inc.

GA

Questioned Costs Internal Control / Segregation of Duties § 200.303

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal polic...

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

View Audit 320765 Questioned Costs: $1

Finding 498097 (2023-005)

Significant Deficiency 2023

Baboquivari Unified School District No. 40

AZ

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.334

2023-005 Allowable Costs/Cost Principles – Indirect Costs U.S. Department of Education Education Stabilization Fund – Assistance Listing No. 84.425 Pass-Through Agency: Arizona Department of Education Pass-Through Number(s): All Pass-Through Numbers Present in the SEFA Recommendation: We recommend m...

2023-005 Allowable Costs/Cost Principles – Indirect Costs U.S. Department of Education Education Stabilization Fund – Assistance Listing No. 84.425 Pass-Through Agency: Arizona Department of Education Pass-Through Number(s): All Pass-Through Numbers Present in the SEFA Recommendation: We recommend management to incorporate a management review control to ensure the calculation is complete and accurate and all supporting documents including the general ledger used for the calculation is retained in accordance with UG. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The district will have a process in place to update all documentation related to indirect costs and the calculations from the general ledger. Name(s) of the contact person(s) responsible for corrective action: Clementina Carlyle, Chief Financial Officer.

View Audit 320760 Questioned Costs: $1

Finding 498052 (2023-003)

Significant Deficiency 2023

Santa Barbara Botanic Garden

CA

Questioned Costs Period of Performance Internal Control / Segregation of Duties § 200.403

Management Response The documentation provided to the auditors did not make it easy for the auditors to trace the general ledger totals to the amounts billed to cost reimbursement contracts. The Garden records all expenses incurred for a given award in its general ledger, regardless of whether ful...

Management Response The documentation provided to the auditors did not make it easy for the auditors to trace the general ledger totals to the amounts billed to cost reimbursement contracts. The Garden records all expenses incurred for a given award in its general ledger, regardless of whether full funding of the expenses is available. This is so the Garden can see the full cost of the activity and make informed decisions in the future. The reports used to bill the federal awards only pulls expenses in the period of the award. In all cases, no amounts were billed to any federal award after the award had expired. Corrective Action Plan Education and reverification of the processes documenting the flow of information from the general ledger to the federal award billings has been provided to accounting personnel involved in federal award accounting and billing. Contact person(s) responsible for the corrective action: Diane Wondolowski, Director of Finance, dwondolowski@sbbotanicgarden.org Anticipated Completion Date: Education on the above has already started and will be completed August 31, 2024.

View Audit 320704 Questioned Costs: $1

Finding 498041 (2023-005)

Significant Deficiency 2023

Santa Barbara Botanic Garden

CA

Questioned Costs Subrecipient Monitoring

Management Response The Garden’s followed the Uniform Guidance requirements on subrecipient monitoring process but did not document its policies and procedures. Corrective Action Plan The Garden has now documented its Federal Subrecipient Monitoring Policy. Education on and reverification of prop...

Management Response The Garden’s followed the Uniform Guidance requirements on subrecipient monitoring process but did not document its policies and procedures. Corrective Action Plan The Garden has now documented its Federal Subrecipient Monitoring Policy. Education on and reverification of proper processes regarding federal subrecipient monitoring transactions will be taken by all principal investigators. Contact person(s) responsible for the corrective action: Diane Wondolowski, Director of Finance, dwondolowski@sbbotanicgarden.org. Anticipated Completion Date: The policy is in writing. Education will be complete by August 31, 2024.

View Audit 320704 Questioned Costs: $1

Finding 498039 (2023-006)

Significant Deficiency 2023

Santa Barbara Botanic Garden

CA

Questioned Costs Cash Management Matching / Level of Effort / Earmarking § 200.303

Management Response The Garden did not draw more on awards than had been incurred over the course of the contract. Adjustments in the general ledger were made in subsequent periods to tie out requested reclasses from program staff. Corrective Action Plan: Education and reverification of the proce...

Management Response The Garden did not draw more on awards than had been incurred over the course of the contract. Adjustments in the general ledger were made in subsequent periods to tie out requested reclasses from program staff. Corrective Action Plan: Education and reverification of the processes documenting the flow of information from the general ledge to the federal award billings has been provided to accounting personnel involved in federal award accounting and billing. Contact person(s) responsible for the corrective action: Jaime Kuczkowski, CPA Jaime@balancefm.com, Diane Wondolowski, Director of Finance, dwondolowski@sbbotanicgarden.org Anticipated Completion Date: Education will be complete by August 31, 2024.

View Audit 320704 Questioned Costs: $1

Finding 498000 (2023-001)

Material Weakness 2023

Klamath Housing Authority

OR

Questioned Costs HUD Housing Programs Material Weakness

Federal Award Findings and Questioned Costs Finding 2023-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs Federal Assistance Listing Numbers: 14.871 and 14.879 Noncompliance – N. Special T...

Federal Award Findings and Questioned Costs Finding 2023-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs Federal Assistance Listing Numbers: 14.871 and 14.879 Noncompliance – N. Special Tests and Provisions – HQS Enforcement Non Compliance Material to the Financial Statements: Yes Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions for the Section 8 Housing Choice Vouchers Program Material Weakness in Internal Control over Compliance for Special Tests and Provisions for the Mainstream Vouchers Program. Criteria: HQS Enforcement. For units under HAP contract that fail to meet HQS, the PHA must require the owner to correct all life threatening HQS deficiencies within 24 hours after the inspections and all other deficiencies within 30 days or within a specified PHA-approved extension. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were failed inspections that did not pass reinspection within 30 days without penalty. Context: There were approximately one hundred and thirty-eight (138) Section 8 Housing Choice Vouchers' units and seven (7) Mainstream Vouchers' units with failed inspections. Of a sample size of fourteen (14) Section 8 Housing Choice Vouchers' and one (1) Mainstream Vouchers' failed inspections, two (2) and one (1) failed inspections, respectively, did not pass reinspection within 30 days. Housing assistance payments were not abated nor was the tenant relocated. Known Questioned Costs: Section 8 Housing Choice Vouchers $814 Mainstream Vouchers $1,608 Cause: There is a significant deficiency for the Section 8 Housing Choice Vouchers Program and a material weakness for the Mainstream Vouchers Program in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance and the Mainstream Vouchers Program is in material non-compliance with the special tests and provisions type of compliance related to HQS enforcement. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs to ensure that established internal control policies related to HQS inspections are being followed on a timely basis. Ann Malfavon, Executive Director, is responsible for implementing this corrective action by December 31, 2024.

View Audit 320673 Questioned Costs: $1

Finding 497999 (2023-003)

Material Weakness 2023

Klamath Housing Authority

OR

Questioned Costs HUD Housing Programs Material Weakness

Finding 2023-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871 Noncompliance – N. Special Tests and Provisions - Reasonable Rent Non Compliance Material to the Financial S...

Finding 2023-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871 Noncompliance – N. Special Tests and Provisions - Reasonable Rent Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions. Criteria: Reasonable Rent. The PHA must do the following: The PHA must determine that the rent to owner is reasonable at the time of initial leasing. Also, the PHA must determine reasonable rent during the term of the contract (a) before any increase in the rent to owner, and (b) at the HAP contract anniversary if there is a 5 percent decrease in the published Fair Market Rent in effect 60 days before the HAP contract anniversary. The PHA must maintain records to document the basis for the determination that rent to owner is a reasonable rent (initially and during the term of the HAP contract) (24 CFR sections 982.4, 982.54(d)(15), 982.158(f)(7), and 982.507). Condition: There were approximately one hundred and sixty-three (163) newly leased units. Of a sample size of sixteen (16) newly leased units, three (3) unit's documentation of reasonable rent did not include the minimum required number of comparable units of three (3), as stated in the Authority's Section 8 Administrative Policy. Known Questioned Costs: $21,531 Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to reasonable rent. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in material non-compliance with the special tests and provisions type of compliance related to reasonable rent. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Ann Malfavon, Executive Director, is responsible for implementing this corrective action by December 31, 2024.

View Audit 320673 Questioned Costs: $1

Finding 497998 (2023-002)

Material Weakness 2023

Klamath Housing Authority

OR

Questioned Costs HUD Housing Programs Eligibility

Finding 2023-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Federal Assistance Listing Numbers: 14.871 Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to the Fi...

Finding 2023-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Federal Assistance Listing Numbers: 14.871 Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions. Criteria: Selections from the Waiting List. The PHA must have written policies in its HCVP administrative plan for selecting applicants from the waiting list and PHA documentation must show that the PHA follows these policies when selecting applicants from the waiting list. Except for as provided in 24 CFR section 982.203(Special admission (non-waiting list)), all families admitted to the program must be selected from the waiting list. “Selection” from the waiting list generally occurs when the PHA notifies a family whose name reaches the top of the waiting list to come in to verify eligibility for admission (24CFR sections 5.410, 982.54(d), and 982.201 through 982.207). Condition: Based upon inspection of the waiting list provided to us during the time of audit, the new move-in list and discussions with management, it could not be determined with any certainty that new move-ins were selected from the wait list in an order that is in accordance with the Authority’s policy. Context: Of a sample size of fifteen (15) Section 8 Housing Choice Vouchers' new move-ins, one (1) could not be traced to the Authority's waiting list. Known Questioned Costs: $4,336 Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to selections from the waiting list. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in material non-compliance with the special tests and provisions type of compliance related to selections from the waiting list. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority agrees with the finding and will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Ann Malfavon, Executive Director, is responsible for implementing this corrective action by December 31, 2024.

View Audit 320673 Questioned Costs: $1

Finding 497995 (2023-003)

Significant Deficiency 2023

County of Washington, Pennsylvania

PA

Questioned Costs Eligibility Student Financial Aid

NEED FROM CLIENT….

View Audit 320671 Questioned Costs: $1

Finding 497966 (2023-003)

Significant Deficiency 2023

Housing Authority of the City of New Britain

CT

Questioned Costs Procurement, Suspension & Debarment § 200.67 § 200.88

Procurement, Suspension and Debarment Description of Findging: For any amounts above the Petty Cash ceiling, but not exceeding $250,000 in accordance with revisions to 2CFR 200.67 and 2 CFR 200.88, the NBHA may use small purchase procedures. Under small purchase procedures, the NBHA shall obtain a...

Procurement, Suspension and Debarment Description of Findging: For any amounts above the Petty Cash ceiling, but not exceeding $250,000 in accordance with revisions to 2CFR 200.67 and 2 CFR 200.88, the NBHA may use small purchase procedures. Under small purchase procedures, the NBHA shall obtain a reasonable number of quotes (preferably three); however, for purchases of less than $10,000, per NDAA Section 806 also known as Micro Purchases, only one quote is required provided the quote is reasonable. Auditors identified 3 instances in which sufficient documentation was not maintained to support the procurement of a vendor. Statement of Concurrence or NonConcurrence: There were 3 instances in which sufficient documentation was not maintained to support the procurement of a vendor. The Authority has not ensured that it is receiving the most competitive prices or rates for services that have been procured, which may have resulted in unnecessary additional costs to the Authority. Corrective Action: Two of the vendors have services that will be put out to bid (landscaping and hazardous cleanup). The third service provided is generally of an emergency nature (plumbing) as we have a licensed plumber on staff. NBHA will make sure we have secured verbal quotes for each occurrence before obligating the vendor. Tracy Blackwell

View Audit 320625 Questioned Costs: $1

Finding 497938 (2023-007)

Material Weakness 2023

Michigan Association of Recovery Residences, Inc.

MI

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Planned Corrective Actions: MARR will retain a CPA consultant to implement a full - range of controls relating to reporting, including federal program reporting. MARR will take such steps as necessary to ensure that reports are timely and accurately prepared, reviewed, and approved prior to filing. ...

Planned Corrective Actions: MARR will retain a CPA consultant to implement a full - range of controls relating to reporting, including federal program reporting. MARR will take such steps as necessary to ensure that reports are timely and accurately prepared, reviewed, and approved prior to filing. All controls, including review and approval will be documented in such documentation to be maintained. MARR will retain a CPA consultant to implement and adopt formal written policies relating to grants management ordered by Uniform Guidance.

View Audit 320567 Questioned Costs: $1

Finding 497937 (2023-006)

Material Weakness 2023

Michigan Association of Recovery Residences, Inc.

MI

Questioned Costs Allowable Costs / Cost Principles Cash Management

Planned Corrective Actions: MARR will retain a CPA consultant to implement a full-range of control over costs charged to federal programs. MARR’s protocol shall ensure that such costs are the direct benefit to the program, are reviewed, approved, documented and ensure the accounting and reporting p...

Planned Corrective Actions: MARR will retain a CPA consultant to implement a full-range of control over costs charged to federal programs. MARR’s protocol shall ensure that such costs are the direct benefit to the program, are reviewed, approved, documented and ensure the accounting and reporting process be accurate. Further, controls over grant billings will be established to ensure expenditures represent actual costs incurred. All control activities, including independent review, should be documented and evidence of review and approval will be maintained.

View Audit 320567 Questioned Costs: $1

Finding 497936 (2023-005)

Material Weakness 2023

Michigan Association of Recovery Residences, Inc.

MI

Questioned Costs Allowable Costs / Cost Principles § 200.405

Planned Corrective Action: MARR will retain a CPA consultant to recommend to management the establishment of procedures and controls to allocate costs between grants based on actual costs attributed to grant and the particular expenditure allowed by the grant. All such allocations will be supported ...

Planned Corrective Action: MARR will retain a CPA consultant to recommend to management the establishment of procedures and controls to allocate costs between grants based on actual costs attributed to grant and the particular expenditure allowed by the grant. All such allocations will be supported by activity-level substantiation and be reviewed. Documentation of the allocation methodology, review and approval will be maintained in writing. MARR will retain a CPA consultant to implement a full-range of control over costs charged to federal programs. MARR's primary decision-making authority regarding such controls shall be placed with the MARR's president. MARR's protocol shall ensure that such costs are the direct benefit to the program, are reviewed, approved, documented and ensure the accounting and reporting process be accurate. Further , controls over grant billings will be established to ensure expenditures represent actual costs incurred. All control activities, including independent review, should be documented and evidence of review and approval will be maintained.

View Audit 320567 Questioned Costs: $1

Finding 497935 (2023-004)

Material Weakness 2023

Michigan Association of Recovery Residences, Inc.

MI

Questioned Costs Period of Performance Allowable Costs / Cost Principles

Planned Corrective Action: MARR will retain a CPA consultant to establish formal written policy documenting significant accounting procedures including but not limited to the independent review of the grant period of performance when recording transactions and preparing grant reimbursement requests....

Planned Corrective Action: MARR will retain a CPA consultant to establish formal written policy documenting significant accounting procedures including but not limited to the independent review of the grant period of performance when recording transactions and preparing grant reimbursement requests. Evidence of the review to be documented and maintained according to the procedures to be implemented.

View Audit 320567 Questioned Costs: $1

Finding 497921 (2023-001)

Material Weakness 2023

Housing Authority of the City of Easton

PA

Questioned Costs HUD Housing Programs Special Tests & Provisions

Authority Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Tyler Martin, ...

Authority Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Tyler Martin, Executive Director, is responsible for implementing this corrective action by December 31, 2024.

View Audit 320526 Questioned Costs: $1

Finding 497657 (2023-001)

Significant Deficiency 2023

Berkshire Community College

MA

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

Corrective Action Plan:. BCC has reviewed its policies and procedures regarding the overaward and has made changes to ensure that funds are processed, calculated correctly, and disbursed/returned within timely manner. $533 has been returned to meet federal requirements/standards and to correct the s...

Corrective Action Plan:. BCC has reviewed its policies and procedures regarding the overaward and has made changes to ensure that funds are processed, calculated correctly, and disbursed/returned within timely manner. $533 has been returned to meet federal requirements/standards and to correct the student record within cost of attendance. Monitoring reports are being created with the assistance of IT and Institutional Effectiveness along with delivered reports from Ellucian. A policy and procedure has been established for when outside resources are received for processing between the Student Financial Services and Business Office. Additional steps will be taken at the time of loan disbursement to ensure proper disbursement and avoidance of overawards. Timeline for Implementation of Corrective Action Plan: Immediately Contact Person: Karrie M. Trautman

View Audit 320442 Questioned Costs: $1

Finding 497550 (2023-003)

Material Weakness 2023

Cornerstone Jefferson-Douglass Academy

MI

Questioned Costs Subrecipient Monitoring Material Weakness

The work done during the year to shore up our monthly close process and ensure we are reconciling our books consistently and timely will aid in addressing this finding as well. We will also engage the auditors to begin the audit process in June, which is 2-3 months before we have been starting to he...

The work done during the year to shore up our monthly close process and ensure we are reconciling our books consistently and timely will aid in addressing this finding as well. We will also engage the auditors to begin the audit process in June, which is 2-3 months before we have been starting to help us ensure audits are completed and submitted on time

View Audit 320292 Questioned Costs: $1

Finding 497505 (2023-002)

Material Weakness 2023

Lifewire

WA

Questioned Costs Subrecipient Monitoring § 200.303

LifeWire’s advocacy team always strives to place survivors into housing where rent is reasonable and in line with fair market rates in eastern Washington. Though it was observed that all rents paid were comparable similar units in the area, our documentation was insufficient to prove we had performe...

LifeWire’s advocacy team always strives to place survivors into housing where rent is reasonable and in line with fair market rates in eastern Washington. Though it was observed that all rents paid were comparable similar units in the area, our documentation was insufficient to prove we had performed these analyses. o After this oversight was brought to our attention, as of June 30, 2024, LifeWire has trained the Housing Team staff on the necessity of completing rent reasonableness evaluations for every participant placed in housing where their rent is paid by the Continuum of Care program. Rent reasonableness assessments are completed by participants’ assigned advocate, reviewed and approved by their supervisor, signed and dated in PDF format, and filed and maintained appropriately. o As of June 30, 2024, LifeWire has implemented an additional 90-day documentation review for every participant in this program. At the 90-day mark, supervisors on the Housing Team review all participant documents to ensure that all compliance requirements are met. o Name of Responsible Individual: Jeannette Biffle, Controller

View Audit 320262 Questioned Costs: $1

Finding 497416 (2023-002)

Material Weakness 2023

Jackson County School District No 5

OR

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.430

2023-002 Allowable Activities/Cost Principles US Department of Education - AL #84.010 Title I Grants to Local Education Agencies Condition: The District was not in compliance wllh lhe Uniform Guidance as it was noted that management of the District was not preparing time and effort dastribution reco...

2023-002 Allowable Activities/Cost Principles US Department of Education - AL #84.010 Title I Grants to Local Education Agencies Condition: The District was not in compliance wllh lhe Uniform Guidance as it was noted that management of the District was not preparing time and effort dastribution records and could not produce source documentation to support the time and etfort applied to payroll expense that was charged to Tatle I Grants to Local Education Agencies. Cause: The District's internal controls to identify and document employees that require support for time and effort charged to Title I Grants to Local Education Agencies were not effective for the year ended June 30, 2023. Auditor Recommendation: We recommend the District review their internal controls to strengthen processes and improve procedures. We recommend the District complete all required time and effort certilications in a timely manner. Plan of Action: Ashland School District wall identify administrative-level staff to oversee federal programs, including Title l, to ensure compliance with all relevant Uniform Guidance activities. Dastrict and building staff will review guidelines and documentation requirements for all federal programs to improve record keeping and to allow appropriate review of federal program activities. Date of lmplementation: lmmediately and ongoing. lf there are any questions regarding this plan, please contact Scott Whitman by email at Scott.Whitman@ashland.k12.or.us or by phone at 54 1 482-281 1.

View Audit 320164 Questioned Costs: $1

Finding 497380 (2023-001)

Significant Deficiency 2023

Presbyterian Healthcare Services

NM

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.318 § 200.319 § 200.320

Finding 2023-001 – Internal control deficiency and noncompliance over Procurement 1) Communication & Awareness: • Debrief by Director, Research and Sponsored Awards with the Community Health Department Senior Leaders and Program Managers regarding the audit finding; including procurement requirem...

Finding 2023-001 – Internal control deficiency and noncompliance over Procurement 1) Communication & Awareness: • Debrief by Director, Research and Sponsored Awards with the Community Health Department Senior Leaders and Program Managers regarding the audit finding; including procurement requirements, the nature of the deficiency and failure points. This occurred on 8/27/2024. • Meeting between Director, Research and Sponsored Awards, PHS Communications and Brand Management leadership and VP of Community Health to communicate procurement requirements and clarify responsibilities for communication of applicability of Federal procurement requirements to specific projects for which advertising services are requested. Initial Meeting occurred 8/28/2024. 2) Training & Education: • Targeted Training with the Community Health department (primary recipient of on-going Federal funding) on Federal procurement requirements. This training will be provided by the Research and Sponsored Awards staff and will be extended to any additional departments new to Federal funding. • Enhancement of existing required annual enterprise-wide leadership training that includes a section on grant funding with increased emphasis on procurement. Research and Sponsored Awards department is responsible for content. • Development of materials for new hires or others new to grant funding who are responsible for federally funded projects (collaboration between Research and Sponsored Awards department and Community Health department) 3) Policies & Procedures: • Written Procedures & Toolkits: Development of written procedures for contracting, exclusion checks and general procurement of goods or services to include checklists / toolkits to facilitate actions required for compliance with Federal procurement rules. • Update to existing policy “Federally funded Grants or Contracts – Procurement / Purchase of Supplies, Services and Other Property” to clarify the responsibilities for communication of applicability of Federal procurement requirements when a department receiving Federal funding procures goods or services through other PHS departments. 4) Collaboration with PHS Marketing department to ensure pathways exist for competitive bids, when necessary, including documentation of processes related to procurements under Federal funding. The first meeting was held 9/12/2024. 5) The Director, Research and Sponsored Awards and Community Health Department will review the items identified as questioned costs to identify if any improper payments were made to PHS. Contact Person: Lori Galves, Director, Research and Sponsored Awards Anticipated Completion Date: December 31, 2024

View Audit 320124 Questioned Costs: $1

Finding 497376 (2023-001)

Significant Deficiency 2023

With Helping Hands Serving Nutritious Meals

TX

Questioned Costs Reporting Significant Deficiency

RE: Finding 2023-001 – Significant Deficiency – Compliance with Daily Meal Count Records not Being Accurately Completed Response The meal count on 7/14/23 and 7/21/23 for King Parkway Mobile Home was incorrect as the server just wrote down the number of meals served and did not circle the numbers a...

RE: Finding 2023-001 – Significant Deficiency – Compliance with Daily Meal Count Records not Being Accurately Completed Response The meal count on 7/14/23 and 7/21/23 for King Parkway Mobile Home was incorrect as the server just wrote down the number of meals served and did not circle the numbers as instructed. This was just a careless error on the server’s part and further training on point of service was needed. The other error on the meal count records was the server indicated 20 meals were served but forgot to circle the very first number on the sheet, therefore there were only 19 numbers circled for the claim. The staff member that was adding the meal count consolidation form perhaps looked at the delivery ticket and not the meal count form to record the number of meals. This too is something that has been addressed and more training was needed. To ensure the Meal Count does not have any errors the Policy & Procedures have been updated as follows: POLICY: Daily Meal Count and Attendance Record (Updated Feb 24) As per TDA Guidelines, a CE must record meal counts and attendance on a daily basis. A CE must record meal counts at the point of service where their staff observe that an eligible child receives a creditable meal. A meal is creditable when a child receives all required components in the correct quantities at the approved mealtime. Daily Meal Count and Attendance Records must be completed at the point of service. POLICY: Meal Service Consolidation (Updated Feb 2024) As per TDA Guidelines each meal must be reported individually. SFSP sites may claim breakfast and supper served to children on week days, weekends, and holidays during a school's summer session. PROCEDURE: “With Helping Hands” (WHH) staff will report each meal separately on the daily meal count form and on a monthly meal consolidation form. The following conditions also apply to the meal service schedule: • The duration of a meal service must not exceed 1 ½ hours for breakfast and 2 hours for supper; • Any meals served outside of the approved meal times will not be claimed or they will be disallowed. • All meals will be recorded at the point of service by the Site Supervisor. • Each site will have their weekly totals and monthly totals reported on the monthly meal consolidation form. • Meal Count Forms will be turned in weekly from the Site Supervisor to the office for processing the claim submission. The office staff and Executive Director will review all documentation prior to claim submission. • Meal Count Consolidation Form will be completed and checked by two staff members’, including the Executive Director. • If the meal count sheet does not match the delivery ticket or any item is missing from the meal count sheet form the meal will be disallowed and further training will be done immediately with the site supervisor and/or staff at that location. • A claim will only be submitted for the meals that are supported by all complete and required documentation.

View Audit 320118 Questioned Costs: $1

Finding 497358 (2023-001)

Significant Deficiency 2023

Maryland Mep, Inc.

MD

Questioned Costs Matching / Level of Effort / Earmarking

Corrective Action: We concur with the recommendation. On an annual basis, Maryland MEP prepares an annual budget detailing Federal and Non-Federal sources and uses of funds which is reviewed and approved by both the NIST MEP Program Office and the NIST Grants Management Division. In the future, M...

Corrective Action: We concur with the recommendation. On an annual basis, Maryland MEP prepares an annual budget detailing Federal and Non-Federal sources and uses of funds which is reviewed and approved by both the NIST MEP Program Office and the NIST Grants Management Division. In the future, Maryland MEP will provide additional clarity and detail on the sources of non-federal cost share.

View Audit 320094 Questioned Costs: $1

Finding 497358 (2023-001)

Significant Deficiency 2023

Maryland Mep, Inc.

MD

Questioned Costs Matching / Level of Effort / Earmarking

The cost sharing in question was not required as the program was eligible for cost-share relief under the legislated guidelines available to the program. A review of these costs is currently being conducted by NIST and Maryland MEP is working closely with NIST to review this open item.

View Audit 320094 Questioned Costs: $1

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