Corrective Action Plans

Finding 522542 (2024-002)

Significant Deficiency 2024

DC

Eligibility Questioned Costs Subrecipient Monitoring

Finding 2024-002: Eligibility – Significant Deficiency in Internal Control over Compliance, Other Matter Compliance Finding Condition: During eligibility testing, we found instances of non-compliance, as follows: TEFAP – We noted that for one out of 20 participants sampled for TEFAP, an ineligible c...

Finding 2024-002: Eligibility – Significant Deficiency in Internal Control over Compliance, Other Matter Compliance Finding Condition: During eligibility testing, we found instances of non-compliance, as follows: TEFAP – We noted that for one out of 20 participants sampled for TEFAP, an ineligible community partner organization was able to order approximately 100 pounds of TEFAP food from CAFB’s website. CSFP – We noted that for one out of 40 individual participants sampled for CSFP, one participant’s original enrollment documents supporting eligibility was missing. The organization did have the participant’s re-enrollment documents for the subsequent fiscal year. This is related to a person being eligible to receive food. Views of Responsible Officials and Planned Corrective Actions: The Organization's investigation into the root causes of the two incidents revealed clerical errors. For the TEFAP incident, a mistake in the partner organization's profile allowed access to USDA food via our online ordering portal. Regarding the CSFP participant, the initial eligibility documents were misplaced, but subsequent reauthorization documents were available. The Organization’s planned corrective actions with respect to the two instances include the following: TEFAP partner eligibility:  Review and enhance existing procedures for establishing partner organization profiles; and  Establish a periodic reconciliation of partner organization’s authorized to access TEFAP commodities in the online ordering portal with a listing of authorized TEFAP partners CSFP eligibility:  Review and enhance existing procedures for filing individual eligibility documents; and  Continued internal reviews by the Organization’s compliance department covering the filing of individual eligibility documents Anticipated Completion Date: March 2025

View Audit 341804 Questioned Costs: $1

Finding 522514 (2024-002)

None 2024

Downers Grove Grade School District 58

IL

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

Management is in the process of implementing a more thorough review to ensure purchase orders have been fulfilled and costs have been incurred in order for expenditures to be recognized in the District's accounting system as well as implementing processes to review open purchase orders on an at leas...

Management is in the process of implementing a more thorough review to ensure purchase orders have been fulfilled and costs have been incurred in order for expenditures to be recognized in the District's accounting system as well as implementing processes to review open purchase orders on an at least monthly basis. Additionally, Management is in the process of implementing secondary review and approval procedures of grant expenditures to ensure all grant expenditures have adequate support prior to being included in claim submission reports.

View Audit 341795 Questioned Costs: $1

Finding 522510 (2024-002)

Material Weakness 2024

Carthage Independent School District

TX

Questioned Costs Procurement, Suspension & Debarment School Nutrition Programs

Action Taken: The district concurs with this finding. Management has clear job duties established and the CFO will be responsible for obtaining approval from TDA for capital asset purchases of $5000 or above.

View Audit 341786 Questioned Costs: $1

Finding 522503 (2024-002)

None 2024

Harrisburg Community Unit School District #3

IL

Questioned Costs Reporting

Finding Type: Compliance and Material Weakness. Name of Contact Person: Amy Dixon, Superintendent. Recommendation: We recommend that the District complete the required logs for each applicable employee. Corrective Action: The District will begin completing the necessary semi-annual certificat...

Finding Type: Compliance and Material Weakness. Name of Contact Person: Amy Dixon, Superintendent. Recommendation: We recommend that the District complete the required logs for each applicable employee. Corrective Action: The District will begin completing the necessary semi-annual certification and will have both the employee and Superintendent sign the certification. Proposed Completion Date: Immediately.

View Audit 341767 Questioned Costs: $1

Finding 522492 (2024-003)

Material Weakness 2024

Westmoreland County Community College

PA

Questioned Costs Special Tests & Provisions Student Financial Aid

Finding 2024-003: Student Financial Aid Cluster Special Tests and Provisions - Return of Title IV Funds View of Responsible Officials and Planned Corrective Action: Challenges with the new SIS resulted in errors in calculations and the delay of the return of Title IV funds to the DOE. After Cases/Ti...

Finding 2024-003: Student Financial Aid Cluster Special Tests and Provisions - Return of Title IV Funds View of Responsible Officials and Planned Corrective Action: Challenges with the new SIS resulted in errors in calculations and the delay of the return of Title IV funds to the DOE. After Cases/Tickets were reported to the SIS the System is now calculating correctly based on system updates and the process of returning funds is working as expected. Human error was a factor in two of the instances noted. The College has implemented internal controls and another level of review of the Return to Title IV calculations and return process based on the functioning of the new SIS.

View Audit 341751 Questioned Costs: $1

Finding 522488 (2024-002)

Material Weakness 2024

Westmoreland County Community College

PA

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles

Finding 2024-002: Student Financial Aid Cluster Allowable Costs and Allowable Activities and Eligibility View of Responsible Officials and Planned Corrective Action: The College has documented procedures in place - Auto packaging and Repackaging within the new SIS calculates Pell awards based on the...

Finding 2024-002: Student Financial Aid Cluster Allowable Costs and Allowable Activities and Eligibility View of Responsible Officials and Planned Corrective Action: The College has documented procedures in place - Auto packaging and Repackaging within the new SIS calculates Pell awards based on the SAI and the Enrollment Intensity of the student (based on new Regulations starting with the 2024-2025 Academic Year). If the Cost of Attendance needs to be manually adjusted, the Financial Aid Staff member will document the breakdown of the COA. System Reports will be reviewed to allow for a secondary review of awards.

View Audit 341751 Questioned Costs: $1

Finding 522482 (2024-003)

Significant Deficiency 2024

Southwest Kansas Area Cooperative, District Number 613

KS

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303

Finding 2024-003 Recommendations: The Director and the accounting department need to create procedures to ensure that both parties are reporting the same expenditures. Within the procedures created, there needs to be checks and balances to ensure that the recording is occurring before reporting figu...

Finding 2024-003 Recommendations: The Director and the accounting department need to create procedures to ensure that both parties are reporting the same expenditures. Within the procedures created, there needs to be checks and balances to ensure that the recording is occurring before reporting figures to the State. Action Taken: We agree with the recommendation. Our targeted implementation date is February 2025.

View Audit 341750 Questioned Costs: $1

Finding 522478 (2024-003)

None 2024

Morning Calm Apt

WA

HUD Housing Programs Questioned Costs Cash Management

FINDINGS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2024-003 Statement of Condition: Management made an unauthorized withdrawal of $4,400 from the residual receipts account during the fiscal year ended June 30, 2022; the funds have not been returned to the residual receipts account. Audito...

FINDINGS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2024-003 Statement of Condition: Management made an unauthorized withdrawal of $4,400 from the residual receipts account during the fiscal year ended June 30, 2022; the funds have not been returned to the residual receipts account. Auditor Recommendation: Management should deposit $4,400 into the residual receipts account to refund the unapproved withdrawals. Management should also contact the HUD Project Manager to develop a plan to get current with vendors and fund the residual receipts account. A rent increase may be necessary. S3800-130: Response Indicator: Agree. S3800-140: Completion Date: February 3, 2025 S3800-150: Action Taken: The board had decided to change property management firms because of the history and severity of financial statement findings and major program fundings prior to the discovery of the unrecorded expenses. The board believes that the new management firm has a properly designed and functioning system of internal controls to prevent such future occurrences. As a result of the discovered unpaid invoices discussed in Finding 2024-001, property management will be unable to make the required residual receipts reserve deposit and pay all vendors without a rent increase from HUD. Management plans to contact the HUD Project Manager to develop a plan to get current with vendors and fund the residual receipts account. A rent increase may be necessary.

View Audit 341741

Finding 522477 (2024-002)

None 2024

Morning Calm Apt

WA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

FINDINGS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2024-002 Statement of Condition: Management only made nine (9) of the twelve (12) monthly required reserve deposits, leaving the account underfunded by $4,053 at June 30, 2022; for the year ended June 30, 2023, only $2,702 of the required ...

FINDINGS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2024-002 Statement of Condition: Management only made nine (9) of the twelve (12) monthly required reserve deposits, leaving the account underfunded by $4,053 at June 30, 2022; for the year ended June 30, 2023, only $2,702 of the required $16,212 in deposits were made, leaving the account behind schedule by another $13,510, for a total deficiency of $17,563; for the year ended June 30, 2024, only $5,404 of the required $16,212 in deposits were made, leaving the account behind schedule by another $10,808, for a total cumulative deficiency of $28,371. Auditor Recommendation: Management should institute a monitoring process to ensure all required monthly deposits to the replacement reserve are made. Such processes could include initiating automatic recurring monthly transfers with the financial institution that maintains the replacement reserve account. We also recommend contacting the HUD project manager to develop a plan to pay all outstanding liabilities and fund the reserve account.. S3800-130: Response Indicator: Agree. S3800-140: Completion Date: February 3, 2025 S3800-150: Action Taken: As a result of the discovered unpaid invoices discussed in Finding 2024-001, property management will be unable to make the required reserve deposits and pay all vendors without a rent increase from HUD. Management plans to contact the HUD Project Manager to develop a plan pay all vendors for amounts owed and fund the reserve account. A rent increase may be necessary.

View Audit 341741

Finding 522476 (2024-004)

Material Weakness 2024

Deptford Township Board of Education

NJ

Questioned Costs Cash Management Reporting

Finding (Condition): The supporting documentation for expenses that the School DIstrict incurred did not agree to amounts requested for reimbursement. Recommendation: That applications for reimbursement are reviewed to ensure that supporting documentation agrees to amounts requested for reimburseme...

Finding (Condition): The supporting documentation for expenses that the School DIstrict incurred did not agree to amounts requested for reimbursement. Recommendation: That applications for reimbursement are reviewed to ensure that supporting documentation agrees to amounts requested for reimbursement. Method of Implementation: Review and enhance internal controls, including report analysis prior to NJDOE Submission. Person Responsible for Implementation: School Business Administrator & Director of Special Education Implementation Date : 02/01/2025

View Audit 341740

Finding 522475 (2024-001)

None 2024

Marysville Quilceda Meadows

WA

Questioned Costs HUD Housing Programs Reporting

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT S3800-030 Statement of Condition: Management did make all of the required deposits to the replacement reserve at June 30, 2024. The annual deposits required were $8,892 but only $5,918 was deposited. S3800-045 Reporting Views of Responsible Official...

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT S3800-030 Statement of Condition: Management did make all of the required deposits to the replacement reserve at June 30, 2024. The annual deposits required were $8,892 but only $5,918 was deposited. S3800-045 Reporting Views of Responsible Officials: Management will design controls to ensure all monthly deposits are made timely. S3800-080: Auditor Recommendation: Management should ensure that the required reserve deposits are made by the required due date. S3800-150: Actions Taken or to be Taken: Management concurs with the auditor’s recommendation, and will design controls to ensure all required deposits are made to the replacement reserve.

View Audit 341738

Finding 522458 (2024-004)

Significant Deficiency 2024

Spearfish School District No. 40-2

SD

Questioned Costs Allowable Costs / Cost Principles

Responsible Individuals: Craig Crosswait, Business Manager Corrective Action Plan: The District will review all time-certifications for accuracy. Anticipated Completion Date: Ongoing

View Audit 341733

Finding 522454 (2024-002)

Significant Deficiency 2024

West Perry School District

PA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

#2024-002 – Allowable Costs/Cost Principles – Time and Effort Certifications Corrective Action Planned: The District has reviewed and revised its controls to ensure that time and effort distribution records are prepared for staff who are charged to federal programs. These records will also be review...

#2024-002 – Allowable Costs/Cost Principles – Time and Effort Certifications Corrective Action Planned: The District has reviewed and revised its controls to ensure that time and effort distribution records are prepared for staff who are charged to federal programs. These records will also be reviewed, approved, and maintained by administrative personnel. A written plan has been developed to guide the process. Anticipated Completion Date: Action has already been taken by the District to resolve the underlying issue of the finding in the current fiscal year. Contact Person Responsible: Cory Hoffman, Business Manager/Board Secretary If the Department of Education has questions regarding this plan, please contact Cory Hoffman, Business Manager/Board Secretary. Sincerely, Cory Hoffman Business Manager/Board Secretary

View Audit 341731

Finding 522424 (2024-001)

Material Weakness 2024

Axis Health System

CO

Questioned Costs Allowable Costs / Cost Principles § 200.400

CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2024 AUDITOR FINDING: 2024‐001 Finding: Allowable Costs and Allowable Activities Certain cost principles were not consistently applied to all expenses. The Organization received a grant for the purpose of expanding electronic health record syst...

CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2024 AUDITOR FINDING: 2024‐001 Finding: Allowable Costs and Allowable Activities Certain cost principles were not consistently applied to all expenses. The Organization received a grant for the purpose of expanding electronic health record systems, which ended in February of 2024; however, the contracted vendor had not completed work for which the grant funds had been appropriated within the 120 day grant close out period. The Organization did not have adequate internal controls in place to ensure cost principles under Uniform Guidance were consistently applied. The Organization should coordinate with HRSA to determine allowability of expenditures incurred. The Organization should add internal controls to monitor that cost principles under Uniform Guidance are consistently applied. PLANNED ACTION: The project period for the HRSA Optimizing Virtual Care (OVC) grant ended on February 28, 2024. The project in question relied heavily on a contract agreement to implement a new Electronic Health Record (EHR) system. The original timeline called for implementation to be complete by January 1, 2024, well within the project period. Due to unforeseen circumstances, the EHR launch date was delayed several times until a confirmed completion date of January 28, 2025 was established. The project scope was fully defined by the contract in place and that contract was paid in full prior to the end of the project period with the OVC funds. The organization has worked with HRSA to determine the best course of action. In addition, training was conducted with the responsible staff to ensure adequate knowledge of federal contract compliance requirements and the appropriate application of “no‐cost extension” requests. Modifications to the internal control procedures regarding federal grant expenditures are under review and will be updated no later than January 31, 2025. RESPONSIBLE PARTY: Ryan Pierce, VP of Finance COMPLETION DATE: January 31, 2025

View Audit 341716 Questioned Costs: $1

Finding 522423 (2024-001)

Significant Deficiency 2024

Albuquerque Housing Authority

NM

Questioned Costs HUD Housing Programs Significant Deficiency

2024-001-(2023-004) MISSING REQUIRED DOCUMENTATION FROM PUBLIC HOUSING FILES (SIGNIFICANT DEFICINCY) AHA has implemented a training program for staff and is hiring a new position Compliance technical review. Responsible Party: Anticipated Completion Date: Finance Director February 2025

View Audit 341712

Finding 522399 (2024-001)

None 2024

Morehead State University

KY

Eligibility Questioned Costs Special Tests & Provisions

Identifying Number: 2024-001 Finding: The provisions of 36 CFR Section 686.31(e) were not followed. Notifications were not sent to TEACH Grant recipients to inform the students of their right to cancel their TEACH Grant and to inform the students of the procedure and time by which the students must ...

Identifying Number: 2024-001 Finding: The provisions of 36 CFR Section 686.31(e) were not followed. Notifications were not sent to TEACH Grant recipients to inform the students of their right to cancel their TEACH Grant and to inform the students of the procedure and time by which the students must notify the institution that he or she wishes to cancel their TEACH Grant or TEACH Grant disbursement. Corrective Actions Taken: We agree with this finding and recommendation. University staff worked with the University's Enterprise System consultants, Ellucian, to develop a procedure to ensure notifications required by 36 CFR Section 686.31(e) are sent to students who receive TEACH Grant funds. Notifications were updated to include language about the right to cancel TEACH Grants and the procedures and time by which the student must notify the institution that he or she wishes to cancel the TEACH Grant or TEACH Grant disbursement. The procedure was implemented to fully comply with 36 CFR Section 686.31(e) on January 30, 2024. Name of Responsible Person: Dr. Heidi Neal, Assistant Vice President of Enrollment Management Completion Date: January 30, 2024

View Audit 341679

Finding 522353 (2024-002)

Significant Deficiency 2024

Catskill Central School District

NY

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

U.S. Department of Education Passed-Through Entity: New York State Department of Education Finding 2024-002 (Significant Deficiency) COVID-19 - Education Stabilization Fund: ARP Homeless II (Assistance Listing# 84.425U) ARP Leaming Loss (Assistance Listing# 84.425U) ESSER II (Assistance Listing# 84....

U.S. Department of Education Passed-Through Entity: New York State Department of Education Finding 2024-002 (Significant Deficiency) COVID-19 - Education Stabilization Fund: ARP Homeless II (Assistance Listing# 84.425U) ARP Leaming Loss (Assistance Listing# 84.425U) ESSER II (Assistance Listing# 84.425D) ARP Summer Enrichment (Assistance Listing# 84.425U) ARP Comprehensive After School (Assistance Listing# 84.425U) ARP ESSER III (Assistance Listing# 84.425U) Compliance Requirements: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Criteria - Expenditures must be used to prevent, prepare for, and respond to COVID-19. These programs are authorized, as applicable, by the Coronavirus Response and Relief Supplemental Appropriations (CRRSA) Act, 2021, Pub. L. No. 116-260 (December 27, 2020), and the American Rescue Plan (ARP) Act of 2021, Pub. L. No. 117-2 (March 11, 2021). The regulations in 34 CRF Part 76 (State Administration), 2 CFR Part 200 (Uniform Administrative Requirements, Cost Principles, and Audit Requirement for Federal Award and 31 CFR Part 205 (Cash Management Improvement Act) apply to these programs. The School District must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in "Standards for Internal Control in the Federal Government" issued by the Comptroller General of the United States or the "Internal Control Integrated Framework", issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). (b) Comply with the U.S. Constitution, Federal statues, regulations, and the terms and conditions of the Federal awards. (c) Evaluate and monitor the non-Federal entity's compliance with statutes, regulations and the terms and conditions of Federal awards. ( d) Take prompt action when instances of noncompliance are identified including noncompliance identified in audit findings. (e) Take reasonable measures to safeguard protected personally identifiable information and other information the Federal awarding agency or pass-through entity designates as sensitive or the non-Federal entity considers sensitive consistent with applicable Federal, State, local and tribal laws regarding privacy and responsibility over confidentiality. Condition/Context - We haphazardly sampled five COVID-19 - Education Stabilization Fund (ESF) expenditures. Our audit procedures found one disbursement where management overrode documented internal control procedures. We viewed invoices, purchase orders, and payment support and noted the disbursement was processed and paid without proper documentation to support the payment made and the payment was processed without the internal claims auditor's review prior to payment. Cause - Management override of established controls. Effect - Revenues and expenditures for one of the ESF grants were overstated prior to adjustment. Adjustment resulted in recording a receivable from the vendor and an offsetting liability to the passthrough agency providing the grant funding. Questioned Costs - None. The improper payment was subsequently adjusted out of expenditures. Recommendation - We recommend that the School District ensures that only disbursements that have been processed and approved by the internal claims auditor to be paid. Management Response - School District management concurs with the finding and will take corrective action. Corrective Action - The Business Office will review and adhere to all cash disbursements procedures and protocols. Completion Date - Effective immediately. Respectfully Submitted, Dr. Brett Miller, Assistant Supt. for Business

View Audit 341608

Finding 522344 (2024-003)

Significant Deficiency 2024

Region One Education Service Center

TX

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking

2024-003 Matching The GEAR UP program will update its review and approval process for in-kind documentation submitted by partners to ensure correct and accurate data is submitted in the annual grant close out process which includes the Annual Performance Report (APR) due to USDE in April 2025. Hourl...

2024-003 Matching The GEAR UP program will update its review and approval process for in-kind documentation submitted by partners to ensure correct and accurate data is submitted in the annual grant close out process which includes the Annual Performance Report (APR) due to USDE in April 2025. Hourly values for teachers and other professionals will be updated on an annual basis. The identified rate has been adjusted to ensure the correct rate is used during final submission of in-kind data for teacher hours in the APR. Proposed Completion Date: April 1, 2025 Name of contact person: Rumalda Ruiz, Deputy Director – Business, Operations, & School Finance Support Contact: (956) 984-6290

View Audit 341604

Finding 522334 (2024-002)

Significant Deficiency 2024

Region One Education Service Center

TX

Questioned Costs Allowable Costs / Cost Principles Eligibility

2024-002 Timely Time and Effort Approvals The Center continues to evaluate its processes related to time and effort. Our Time and Effort electronic system has been evaluated and enhancements are forthcoming to include robust functionalities to include timely supervisor approval notifications. Propos...

2024-002 Timely Time and Effort Approvals The Center continues to evaluate its processes related to time and effort. Our Time and Effort electronic system has been evaluated and enhancements are forthcoming to include robust functionalities to include timely supervisor approval notifications. Proposed Completion Date: May 31, 2025 Name of contact person: Rumalda Ruiz, Deputy Director – Business, Operations, & School Finance Support Contact: (956) 984-6290

View Audit 341604

Finding 522330 (2024-002)

Material Weakness 2024

Rockingham County

NC

Questioned Costs Eligibility Reporting

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Section III Federal Award Findings and Questioned Costs Management will review cases internally to ensure proper documentati...

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Section III Federal Award Findings and Questioned Costs Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented sources of income/resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 1, 2024 Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire - Medicaid Supervisors Corrective actions for finding 2024-001 and 2024-002 also apply to the State Awards findings. Management will provide refresher training to all staff on what processes to follow when changes are reported to ensure accurate and timely review of all benefits. Management will review and revise current procedures in place to ensure that all eligibility determination criteria and documentation is completed timely and accurately reflected in the case file within the NC Fast Case Management System. Training will be completed by November 1, 2024

View Audit 341596

Finding 522329 (2024-001)

Material Weakness 2024

Rockingham County

NC

Questioned Costs Eligibility Reporting

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Section III Federal Award Findings and Questioned Costs Management will review cases internally to ensure proper documentati...

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Section III Federal Award Findings and Questioned Costs Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented sources of income/resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 1, 2024 Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire - Medicaid Supervisors Corrective actions for finding 2024-001 and 2024-002 also apply to the State Awards findings. Management will provide refresher training to all staff on what processes to follow when changes are reported to ensure accurate and timely review of all benefits. Management will review and revise current procedures in place to ensure that all eligibility determination criteria and documentation is completed timely and accurately reflected in the case file within the NC Fast Case Management System. Training will be completed by November 1, 2024

View Audit 341596

Finding 522305 (2024-002)

Significant Deficiency 2024

School District of the City of Hazel Park

MI

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

See Corrective Action Plan for Chart/Table

View Audit 341580

Finding 522285 (2024-001)

Material Weakness 2024

Commonspirit Health

IL

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2024-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long...

REFERENCE: 2024-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long Beach and Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. At Bailey-Boushay House, one employee’s salary that was charged to the grant was not supported by the underlying timesheet for the respective pay period and the related expenditures should not have been charged to the grant and requested for reimbursement. Corrective Action Plan: At St. Mary Medical Center – Long Beach, the leadership team implemented a timecard review process to ensure timecards are properly signed off and approved each pay period, with exceptions confirmed via email from the appropriate manager. At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders are sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The executive director ensures supervisory follow-up with each name that shows up in the audit report each pay period by Kronos Reports. The Finance Manager reviews the timecard allocations and populates the hours charged to the grant per the timecard on to the salary allocation spreadsheet. The salary allocation spreadsheet is utilized in completing the reimbursement request. The salary allocation spreadsheet is reviewed by the Director of Outpatient Programs as part of the reimbursement request approval process. The questioned costs will be refunded by Bailey-Boushay House to the grantor in February 2025. Person Responsible: Vo Phay Sin, Controller – St. Mary Medical Center, Long Beach Rob Hays, Executive Director – Bailey Boushay House Completion: April 2024 (control implementation) Expected Completion: February 2025 (compliance corrective action)

View Audit 341568 Questioned Costs: $1

Finding 522263 (2024-003)

Material Weakness 2024

Hall County Housing Authority

NE

Questioned Costs Subrecipient Monitoring Eligibility

Corrective Action Plan Contact Person Artena Thompson 1834 W 7th Street Grand Island, NE 68803 (308) 385-5530 Finding 2024-001 Management has recognized the finding and will familiarize themselves with the requirements of these documents to ensure the proper procedures are followed and the proper do...

Corrective Action Plan Contact Person Artena Thompson 1834 W 7th Street Grand Island, NE 68803 (308) 385-5530 Finding 2024-001 Management has recognized the finding and will familiarize themselves with the requirements of these documents to ensure the proper procedures are followed and the proper documents are retained in the tenant files. Finding 2024-002 Management will familiarize themselves with the requirements and guidelines of their ACOP to better ensure that the Authority is operating and maintaining its policies. Finding 2024-003 See Finding 2024-001.

View Audit 341542

Finding 522250 (2024-001)

Significant Deficiency 2024

San Leandro Supportive Housing, Inc.

CA

Questioned Costs HUD Housing Programs Cash Management

1. Finding 2024-001 a. Comments on the Finding and Each Recommendation Management concurs that the Project withdrew from the residual receipts reserve in the amount of $8,409 without HUD approval. Management is in agreement with the recommendation to deposit $8,409 into the residual receipts reserve...

1. Finding 2024-001 a. Comments on the Finding and Each Recommendation Management concurs that the Project withdrew from the residual receipts reserve in the amount of $8,409 without HUD approval. Management is in agreement with the recommendation to deposit $8,409 into the residual receipts reserve. b. Action(s) Taken or Planned on the Finding Management has made changes to internal controls to prevent and detect unauthorized withdrawals from reserves. Management further notes that they have re-trained staff, and reaffirmed the review and approval process to ensure required residual receipt reserve withdrawals are completed with proper HUD authorization. Management will complete the required reimbursement to the residual receipts reserve by October 31, 2024.

View Audit 341508 Questioned Costs: $1

Corrective Action Plans

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