Corrective Action Plans

Finding 391611 (2023-004)

Material Weakness 2023

City of Eureka

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Finding – The City did not have adequate internal controls to ensure compliance with time and effort requirements. Name of contact person: Lane Millar, Finance Director Corrective action: The City has revised its internal controls to guarantee compliance with time and effort requirements. Furth...

Finding – The City did not have adequate internal controls to ensure compliance with time and effort requirements. Name of contact person: Lane Millar, Finance Director Corrective action: The City has revised its internal controls to guarantee compliance with time and effort requirements. Furthermore, the City plans to engage external professional and technical services for the management of significant State and Federal Grants. Proposed completion date: March 1, 2024

View Audit 302063 Questioned Costs: $1

Finding 391597 (2023-001)

Significant Deficiency 2023

Thatcher Unified School District No. 4

AZ

Equipment & Real Property Management Questioned Costs Procurement, Suspension & Debarment § 200.313 § 200.439

CORRECTIVE ACTION PLAN U.S. Department of Education Thatcher Unified School District No. 4 respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The findings from the schedule of findings and questioned costs are discus...

CORRECTIVE ACTION PLAN U.S. Department of Education Thatcher Unified School District No. 4 respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS— FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS Finding Number: 2023-001 Repeat Finding: Yes Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425D and 84.425U Federal Agency: U.S. Department of Education Federal Award Number: 23SSPCON-311221-01A, 21FESSII-111221-01A, 21FESIII-111221-01A Questioned Costs: None Type of Finding: Noncompliance, Significant Deficiency Compliance Requirement: Equipment/Real Property Management Condition/Context: The District did not tag and track the capital assets purchased with Education Stabilization Fund monies. Action planned in response to finding: Management will establish procedures to ensure all assets are properly tagged and tracked to prevent theft, fraud, or misuse of District assets. Planned completion date for corrective action plan: For the period ending June 30, 2024. Name of the contact person responsible for corrective action: Clay Bowman, Director of Finance

View Audit 302058

Finding 391588 (2023-001)

Material Weakness 2023

Mono County Office of Education

CA

Questioned Costs Special Tests & Provisions Eligibility

April 1, 2024 Finding Number 50000 (2023-001) Noncompliance and Internal Control over Federal Compliance Federal Program – Child Care and Development Fund Cluster – Assistance Listing 93.575 and 93.576, Federal Alternative Payment Corrective Action Plan: Anticipated Completion Date April 30, 2024...

April 1, 2024 Finding Number 50000 (2023-001) Noncompliance and Internal Control over Federal Compliance Federal Program – Child Care and Development Fund Cluster – Assistance Listing 93.575 and 93.576, Federal Alternative Payment Corrective Action Plan: Anticipated Completion Date April 30, 2024 Prior to Mono County Office of Education (MCOE) taking over this program, another agency was responsible for the original eligibility determinations and special tests and provisions, including the files selected for this audit. After discussion about the audit findings, MCOE investigated further, and it was noted that the staff at the time were not following the procedures and forms that were in place. Items were either not completed or filled out correctly in many instances. Since this discovery, MCOE has developed a corrective action plan as follows to adhere to the program’s requirements: • MCOE will ensure that existing and new staff are trained to adhere to the policies and procedures for the program. • MCOE will be conducting annual reviews of all service providers and children served to ensure MCOE is maintaining the required documents on file. • MCOE has developed a double-check procedure to ensure that staff is keeping the required documentation on file for both providers and children served moving forward. I, Jennifer Weston, CBO, will be responsible for the implementation and monitoring of the corrective action plan. Sincerely, Jennifer Weston Chief Business Officer Mono County Office of Education

View Audit 302045 Questioned Costs: $1

Finding 391582 (2023-013)

Material Weakness 2023

The City of New York

NY

Internal Control / Segregation of Duties Questioned Costs Eligibility § 200.303

Finding No. 2023-013 Department(s): New York City Administration for Children’s Services and New York City Human Resources Administration Program(s): Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s): ACS: ACS will work with other agencies to promote co...

Finding No. 2023-013 Department(s): New York City Administration for Children’s Services and New York City Human Resources Administration Program(s): Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s): ACS: ACS will work with other agencies to promote compliance and internal controls going forward. HRA: In response to the findings, HRA made the following training requests to address the specific findings identified in this audit: 1. Training ID 2344 - Childcare liaisons and Childcare Review Team (CCRT) require training for the appropriate documentation necessary for the approval and provision of childcare. Audit findings confirmed that the staff charged with approval and authorizing childcare will take refresher training about the appropriate documentation requirements (i.e., CS-274w, LDSS 4699, LDSS 4700, etc.). The training will emphasize the requirement that any approved childcare must have support underlying employment/education documentation to justify the provision of the childcare. Childcare is a supportive service, so any childcare must have employment/engagement/education as a condition precedent. 2. Training ID 2343 - The training will include information about the client's employment, rate of pay, frequency of pay, and getting the appropriate documentation into the case records. Audits confirmed that 1) when the agency budgeted income and approved supportive services (i.e., childcare), the record did not have supporting income and employment related documents; 2) training will include the process for budgeting the earned income and applied any earned income disregards. Anticipated Completion Date: April 2024 and ongoing Person(s) Responsible for Implementation: ACS: Rahel Getachew, Associate Commissioner (212)-676-8818. HRA: Ramon E. Flores, Deputy Commissioner, Family Independence Administration (FIA) floresra@hra.nyc.gov

View Audit 302042 Questioned Costs: $1

Finding 391579 (2023-008)

Significant Deficiency 2023

The City of New York

NY

Internal Control / Segregation of Duties Questioned Costs Reporting § 200.303

Finding No. 2023-008 Department(s): New York City Department of Health and Mental Hygiene Program(s): Assistance Listing Number 93.323, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Corrective Action(s): DOHMH agrees with the recommendation that “DOHMH strengthen its intern...

Finding No. 2023-008 Department(s): New York City Department of Health and Mental Hygiene Program(s): Assistance Listing Number 93.323, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Corrective Action(s): DOHMH agrees with the recommendation that “DOHMH strengthen its internal controls over the reporting process to include documented review and approval of all financial and special performance reports prior to submission within the required timeframe.” DOHMH Finance will ensure sufficient time to meet and discuss the status of spending and plans for remaining balance before the end of the award period. For example, such meeting will occur at least a month before the end of the award period. DOHMH Finance will ensure sufficient time for review and approval process of the FFR and submit within the required timeframe. For example, send annual FFR for program review at least 2 weeks before the report deadline. Approval deadline date will be added to the approval email and followed up on a consistent basis. The Division of Disease Control will document review of ELC-related reports prior to submission. Anticipated Completion Date: Effective Immediately; 3/20/2024 Person(s) Responsible for Implementation: Anthony Faciane, Assistant Commissioner, afaciane@health.nyc.gov Wai ting Yu, Assistant Commissioner, wyu4@health.nyc.gov Jennifer Carmona, Senior Director, jcarmona@health.nyc.gov Yuming Li, Director, yli@health.nyc.gov Xiu mei Mai, Director, xmai@health.nyc.gov Jenny Tejada, Director, jtejada@health.nyc.gov James Chan, Assistant Director, jchan6@health.nyc.gov Inna Dubrovenska, Assistant Director, idubrovenska@health.nyc.gov Yulia Gudzinskiy, Grants Manager, ygudzinskiy@health.nyc.gov

View Audit 302042

Finding 391570 (2023-001)

None 2023

The City of New York

NY

Questioned Costs Reporting

Finding No. 2023-001 Department(s): New York City Department of Education Program(s): Assistance Listing Numbers: 84.010, Title I Grants to Local Educational Agencies 84.287, Twenty-First Century Community Learning Center 84.365, English Language Acquisition Grants 84.367, Supporting Effective I...

Finding No. 2023-001 Department(s): New York City Department of Education Program(s): Assistance Listing Numbers: 84.010, Title I Grants to Local Educational Agencies 84.287, Twenty-First Century Community Learning Center 84.365, English Language Acquisition Grants 84.367, Supporting Effective Instruction State Grant Corrective Action(s): The DOE continues to recognize the importance of fiscal reporting requirements and has developed and maintains processes and procedures to monitor grant award programs with respect to the timely submission of Final Expenditure Reports (“FS-10F”). In addition to the established measures taken in prior years, for FY21 and FY22, a new report listing encumbrances open in excess of 29 days was developed by the Division of Financial Operations (“DFO”), System Development and Support, in conjunction with the Office of Revenue Operations (“ORO”) and contains separate tabs reflecting whether a good or service has been received, partially received, certified or received in full. This report has been placed on the Cognos menu of each of Field Support Centers to assist in identifying bottlenecks and obstacles that need to be addressed. We had hoped that as the program staff become familiar with this report that it would serve as a tool for addressing open items. Unfortunately, the large staff turnover hampered this effort. However, we are continuing these efforts to ensure new staff members are properly trained on utilizing these reports. The DOE reviews programs/schools throughout the award and re-enforces established reporting guidelines to facilitate timely submission of expenditure reports. The DOE continues to closely track grant expenditures throughout the grant period, monitoring programs/schools to facilitate accurate and complete records, as well as work with appropriate State Education officials to facilitate the completion and submission of financial expenditure reports. The DOE has incorporated applicable deadlines related to encumbrances and payment certifications into the Fiscal 2024 close calendar in an effort to continue to reinforce the need for the timely payment and takedown of open encumbrances. This message is regularly stressed at close meetings and through e-mails to applicable parties throughout the course of the close process. With respect to the audit finding, the DOE will reemphasize the importance of closing applicable transactions to facilitate timely submission of FS-10F reports. Anticipated Completion Date: Ongoing Person(s) Responsible for Implementation Barry Elkayam, Executive Director, Office of Revenue Operations (718) 935-5050

View Audit 302042

Finding 391560 (2023-004)

Significant Deficiency 2023

The City of New York

NY

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303

Finding No. 2023-004 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.241, Housing Opportunities for Persons with Aids Corrective Action(s): HASA will revamp its contract monitoring policies and procedures to ensure sampling of housing inspectio...

Finding No. 2023-004 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.241, Housing Opportunities for Persons with Aids Corrective Action(s): HASA will revamp its contract monitoring policies and procedures to ensure sampling of housing inspection reports and related maintenance and repairs documentation are included to assess compliance with housing quality standards. Documentation reviewed will also include confirmation of apartments’ readiness prior to occupancy and corrective action measures taken to address outstanding deficiencies, including failed inspections. Anticipated Completion Date: April 1, 2024 and ongoing Person(s) Responsible for Implementation: Xiomara Pamela Farquhar, Assistant Deputy Commissioner farquharx@hra.nyc.gov

View Audit 302042

Finding 391559 (2023-006)

None 2023

The City of New York

NY

Special Tests & Provisions Questioned Costs Subrecipient Monitoring

Finding No. 2023-006 Department(s): New York City Department of Housing Preservation and Development Program(s): Assistance Listing Number 14.239, HOME Investment Partnership Program Corrective Action(s): The Department of Housing Preservation and Development (HPD) continues to maintain processes ...

Finding No. 2023-006 Department(s): New York City Department of Housing Preservation and Development Program(s): Assistance Listing Number 14.239, HOME Investment Partnership Program Corrective Action(s): The Department of Housing Preservation and Development (HPD) continues to maintain processes and procedures supporting compliance with Housing Quality (HQ) inspection standards. HPD routinely conducts HQS inspections of HOME Investment Partnership Program assisted rental units and continues to maintain systems to facilitate and promote compliance with HOME inspection requirements; HPD inspects HOME units periodically and follows up on failed inspections routinely. Further, HPD continues to review program requirements and operations to enhance program oversight and ensure the timeliness of repairs. As part of HPD’s ongoing effort to accomplish complete and timely repairs of all HOME units, building owners are notified of failed inspections, and regularly provided with detailed reports identifying non-compliant conditions. HPD also continues to impress upon owners the critical importance of completing timely repairs of all HOME units. Building owners are notified of failed inspections and provided detailed reports regularly, identifying non-compliant conditions. With respect to the finding, HPD recognizes that in six (6) instances, the Certification of Repair was not submitted within the 90-day timeframe. HPD is currently sending out non-compliance letters and will continue to follow-up with the owner(s) until all required repairs are certified as complete. In addition, HPD will consider, on a case-by-case basis, documenting its rationale for not exercising extreme remedies (such as withdrawal of future funding) for failure to complete repairs within the 90-day cure period. Anticipated Completion Date: June 2023 and ongoing Person(s) Responsible for Implementation: Arabia Brown, Director, Tax Credit and HOME Compliance (212) 863-8204

View Audit 302042

Finding 391558 (2023-002)

Material Weakness 2023

The City of New York

NY

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 200.303

Finding No. 2023-002 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): This FY23 audit was conducted on the heels of the FY22 audit where the questioned cost finding is a similar er...

Finding No. 2023-002 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): This FY23 audit was conducted on the heels of the FY22 audit where the questioned cost finding is a similar error type but significantly decreased to $296 from over $18,000. Included in the FY22 recommended Corrective Action was the onboarding of the Executive Director to shepherd the charge with strengthening the teams’ internal governance, appropriate monitoring and future compliance. Adversely, the onboarding of the executive director was lengthy and only recently finalized in the 2nd quarter of FY24. HRA agrees to strengthen internal controls and the new Executive Director is working with the team to ensure they are intentional in appropriately applying the correct formula for calculating allowable cost, particularly the inclusion of “gross” and not “net” income. The Quality Assurance Tool has been updated including specific sub-items to ensure allowable cost is correctly calculated as well as the other deliverables. Corrective Action(s) • Strengthen internal governance and future compliance. • Executive Director for the Home-TBRA now on board. • Update the Quality Assurance tool that includes sub-items information that supports improved review and approval. • Provide refresher training for staff involved with TBRA to improve performance and outcomes. Anticipated Completion Date: June 30, 2024 and ongoing Person(s) Responsible for Implementation: Dori Hopkins-Figeroux, Director - HTBRA hopkinsfigerouxd@hra.nyc.gov 929-252-6089 Jordan Worrell, Executive Director RAP/HTBRA worrellj@hra.nyc.gov 929-252- 5403 Dwana Abraham, Assistant Deputy Commissioner abrahamd@hra.nyc.gov 929-221-6726

View Audit 302042 Questioned Costs: $1

Finding 391557 (2023-003)

None 2023

The City of New York

NY

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs

Finding No. 2023-003 Department(s): New York City Department of Human Resources Administration Program(s): Assistance Listing Number 14.231, Emergency Solutions Grants Program Corrective Action(s): The oversight in 2022 (regarding obligation of the 2021 grant) occurred prior to the initiation of...

Finding No. 2023-003 Department(s): New York City Department of Human Resources Administration Program(s): Assistance Listing Number 14.231, Emergency Solutions Grants Program Corrective Action(s): The oversight in 2022 (regarding obligation of the 2021 grant) occurred prior to the initiation of the Corrective Action Plan implemented to strengthen the internal controls based on the FY 2022 Single Audit finding (regarding obligation of the 2020 grant). As indicated in our response to the FY 2022 finding, we will ensure in the future that we strengthen our internal controls to ensure that 100% of the total ESG grant amount is obligated within 180 days of the signed grant agreement. This will include an added layer of review by the Associate Commissioner of Homeless Policy and Innovation, who oversees the unit that obligates the funds in IDIS. Additionally, as communicated in the ICQ, Federal Homeless Policy and Reporting (“FHPR”) and Finance have detailed the following process: • FHPR will notify Finance when the new ESG funding is awarded and the total amount. • Finance will contact OMB to share that a new award was announced and to expect an updated FY budget construct. • FHPR will work with Programs to confirm funding allocations and will send an updated construct to Finance. • Finance will share updated construct with OMB. • FHPR will use updated construct to complete all funding obligations in IDIS. • FHPR will set progressive reminders following ESG award announcements to ensure the 180-day deadline is met. Going forward, these activities and action steps will be completed by a dedicated ESG staff person working within the FHPR team. This new position was created and posted, and a candidate was selected in late 2023; we expect to onboard the selected candidate shortly. Anticipated Completion Date: May 1, 2024 Person(s) Responsible for Implementation: Martha Kenton, Executive Director, Continuum of Care kentonm@dss.nyc.gov 929-221-6283 ESG Project Manager, candidate currently in the onboarding process

View Audit 302042

Finding 391538 (2023-001)

None 2023

City of Tucker, Georgia

GA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

The Finance Department personnel will carefully review vendor status in the System for Award Management and produce documentation of eligibility for use of Federal Funds before procurement of goods and services.

View Audit 302016 Questioned Costs: $1

Finding 391472 (2023-001)

Significant Deficiency 2023

American International College

MA

Questioned Costs

Corrective Action Plan: In March of 2023, the College created a policy that implemented scheduled disbursement dates to ensure the timely recording of disbursement dates. The dates of the finding were before the new policy was in effect. To further mitigate this from occurring in the future, the C...

Corrective Action Plan: In March of 2023, the College created a policy that implemented scheduled disbursement dates to ensure the timely recording of disbursement dates. The dates of the finding were before the new policy was in effect. To further mitigate this from occurring in the future, the College has implemented a report that will show differences in the date Direct Student Loan funds are disbursed in Powerfaids versus the date the funds are applied to a student’s ledger, and date shown as disbursed in COD. All differences will be investigated and rectified on a biweekly basis. This will be implemented by the college in March 2024. Timeline for Implementation of Corrective Action Plan: Implemented in March 2024 Contact Person Richard O’Connor Director of Financial Aid

View Audit 301961

Finding 391471 (2023-002)

Material Weakness 2023

University of Maryland Medical System Corporation

MD

Reporting Questioned Costs Subrecipient Monitoring

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2023 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) respectfully submits the following corrective action plan for the year ended June 30,2023. Audit p...

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2023 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) respectfully submits the following corrective action plan for the year ended June 30,2023. Audit period: July 1, 2022 to June 30, 2023 MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE 2023-002 Reporting of Schedule of Expenditures of Federal Awards Assistance Listing Number 97.036 – COVID-19 – Disaster Grants – Public Assistances (Presidentially Declared Disasters) Recommendation: The Corporation’s policy and procedures should be designed to ensure expenditures are reported on the Schedule based on the date on which the expenditures are incurred as required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management will continue to refine internal procedures and practices. The COVID-19 pandemic grant programs included evolving expectations which did not follow the typical grant process. We will enhance procedures to review related report submissions, obligated worksheets, and incurred expenditures in conjunction with review of the Schedule to verify completeness and accuracy. Planned completion date for corrective action plan: September 30, 2024 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 301956

Finding 391467 (2023-003)

None 2023

City of Westminster, Maryland

MD

HUD Housing Programs Questioned Costs

The Director of Housing confirmed with a HUD representative that the "General Depository Agreement," HUD Form 51999 (GDA) with an expiration date of 08/31/2023 is the most recent HUD form. The city is currently working with the bank to obtain signatures/execute the form. The Director of Housing will...

The Director of Housing confirmed with a HUD representative that the "General Depository Agreement," HUD Form 51999 (GDA) with an expiration date of 08/31/2023 is the most recent HUD form. The city is currently working with the bank to obtain signatures/execute the form. The Director of Housing will notify the Finance Director when the current form expires and the Finance Director will ensure a new depository agreement is signed.

View Audit 301948 Questioned Costs: $1

Finding 391465 (2023-002)

None 2023

City of Westminster, Maryland

MD

Questioned Costs Allowable Costs / Cost Principles

The City has developed a time study that will be completed by the Director of Housing one week per quarter. This time study will identify the Director of Housing's time spent on HUD vs. other activities and the percentage of time spent on HUD will be used to appropriately allocate the Director of Ho...

The City has developed a time study that will be completed by the Director of Housing one week per quarter. This time study will identify the Director of Housing's time spent on HUD vs. other activities and the percentage of time spent on HUD will be used to appropriately allocate the Director of Housing's salary and benefit costs to the HUD program. The initial time study was completed in January 2024; another will be done in April 2024. These will be used to allocate The Director of Housing's salary and benefits for FY24.

View Audit 301948 Questioned Costs: $1

Finding 391459 (2023-001)

Significant Deficiency 2023

City of Westminster, Maryland

MD

Questioned Costs Subrecipient Monitoring Reporting

The finance department experienced staff turnover and vacancies during the fiscal year, impacting the fiscal year end close processes. We have consulted with a fractional CFO and are now fully staffed. We are working to remedy the items noted above by assessing our current procedures and implementin...

The finance department experienced staff turnover and vacancies during the fiscal year, impacting the fiscal year end close processes. We have consulted with a fractional CFO and are now fully staffed. We are working to remedy the items noted above by assessing our current procedures and implementing changes for more effective and efficient financial reporting. We are also in the final stages of selecting new ERP software, which would be implemented during fiscal years 2025 and 2026 to allow for more streamlined processes to be implemented. We will be developing comprehensive year end close and audit preparation procedures that will ensure a timely close of the fiscal year.

View Audit 301948

Finding 391445 (2023-002)

None 2023

Cobb County Board of Health

GA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

Views of Responsible Officials and Planned Corrective Action: The Board agrees with this recommendation and will review internal procedures relating to data that will support the allocation of personnel costs.

View Audit 301940 Questioned Costs: $1

Finding 391440 (2023-001)

Significant Deficiency 2023

Community Action Partnership of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303

Corrective Action: Susan Matlack Jones (SMJ) took over as CAPO’s fiscal service provider in July of 2022. The first six months were spent largely cleaning and correcting journal entries from FY22 – a significant task. CAPO did not begin to receive truly accurate and trustworthy financial statements ...

Corrective Action: Susan Matlack Jones (SMJ) took over as CAPO’s fiscal service provider in July of 2022. The first six months were spent largely cleaning and correcting journal entries from FY22 – a significant task. CAPO did not begin to receive truly accurate and trustworthy financial statements until early in 2023. CAPO also experienced two staff losses in the finance department from March through May of 2023. In light of our growth and increased administrative needs, we revised our job posting to increase the level of fiscal skill and responsibility needed for the Finance Manager role. In September of 2023, CAPO was successful in hiring a Finance and Grants Manager with experience in federal fund accounting for Community Action and in SSVF (our major grant). Since that time, he has organized, revamped, and significantly improved internal processes to assure timely review of all finances and reconciliations and works closely with SMJ to assure overall accuracy. Person Responsible: Janet Allanach, CAPO Executive Director Timing for Implementation: Complete as of October 2023

View Audit 301926

Finding 391403 (2023-002)

Significant Deficiency 2023

County of Nevada

CA

Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.403 § 200.430 § 200.431

The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are r...

The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are recognized in accordance with cost principles, statues, regulations, and terms and conditions of federal awards.

View Audit 301919

Finding 391390 (2023-003)

Significant Deficiency 2023

Bethany Lutheran College, Inc.

MN

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

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend the College implements policies to review all student award packages at the start of the academic year to ensure no over awards exist. Explanation of disagreement...

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend the College implements policies to review all student award packages at the start of the academic year to ensure no over awards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office looks for over award situations throughout the academic year, as changes to Cost of Attendance and financial aid (Scholarships/Grants, Loans, and Work- Study earnings) can change throughout the year. That said, Financial Aid Staff (Jeff Younge and/or Sally Sorensen) will review every student for potential over awards during the 1st two weeks of fall semester (beginning August 20, 2024), to catch any over awards that may have been created between the time of packaging, and beginning of the academic year. Name of the contact person responsible for corrective action: Jeff Younge, Director of Financial Aid Planned completion date for corrective action plan: 3/26/2024

View Audit 301916 Questioned Costs: $1

Finding 391374 (2023-005)

Significant Deficiency 2023

Board of Education of Prince George's County Maryland

MD

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.344

Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit fin...

Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024

View Audit 301912 Questioned Costs: $1

Finding 391341 (2023-004)

Significant Deficiency 2023

Board of Education of Prince George's County Maryland

MD

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.344

Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is...

Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024

View Audit 301912 Questioned Costs: $1

Finding 391338 (2023-001)

Material Weakness 2023

Lifespire, Inc.

NY

Allowable Costs / Cost Principles Questioned Costs Reporting

The main reason for the discrepancy in income was a result of using actual units/services billed (from the billing software) and not what is recorded in the financials because, usually what is recorded every month in the financials is based on estimates and later adjusted based on actual billing and...

The main reason for the discrepancy in income was a result of using actual units/services billed (from the billing software) and not what is recorded in the financials because, usually what is recorded every month in the financials is based on estimates and later adjusted based on actual billing and payments for services received. With this approach we were comfortable that, if necessary, we could trace the income to the actual service rather than an estimate. An unintended consequence was that income received in a year for a service in a prior year was not accounted for. While, immaterial, this resulted in discrepancies. We are committed that in the future, we would take additional steps to review the information by other employees who are not involved in the process in order to get a different perspective, and seek outside help, like a CPA, if necessary.

View Audit 301904

Finding 391324 (2023-006)

Material Weakness 2023

Ashley Medical Center

ND

Questioned Costs Material Weakness Reporting § 200.303

Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supp...

Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supported. These were improperly included within the HHS Report Period 4 and caused the Report to be inaccurate. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391323 (2023-005)

Material Weakness 2023

Ashley Medical Center

ND

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lo...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lost revenue ca lculation option i which is actual to actual methodology of calculating lost revenues attributable to coronavirus. The Medical Center did not incorporate the financial audit adjustments into the actual revenue amounts reported within the HHS special report for the fiscal years 2019, 2020, and 2021. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure the lost revenue calculation is supported by internal financia ls. We will also implement control policies to ensure a secondary review and approval over the final lost revenue calculation. Anticipated Completion Date: 6/30/2024

View Audit 301891

Corrective Action Plans

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