Corrective Action Plans

Finding 388469 (2023-004)

Significant Deficiency 2023

NJ

Questioned Costs Student Financial Aid Significant Deficiency

Unofficial Withdrawals Planned Corrective Action: The University will run zero credit reports at the end of each semester to ensure all potential unofficial withdrawals are followed up on so that R2T4’s are completed timely when required. Person Responsible for Corrective Action Plan: Nicholas Cap...

Unofficial Withdrawals Planned Corrective Action: The University will run zero credit reports at the end of each semester to ensure all potential unofficial withdrawals are followed up on so that R2T4’s are completed timely when required. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: June 30th, 2024

View Audit 300191 Questioned Costs: $1

Finding 388467 (2023-003)

Significant Deficiency 2023

Saint Elizabeth University

NJ

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

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates...

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates reflect the actual disbursement date. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024

View Audit 300191

Finding 388460 (2023-001)

Significant Deficiency 2023

Brooklyn Law School

NY

Eligibility Questioned Costs Significant Deficiency

2023-001 Program Eligibility—Significant Deficiency United States Department of Education - ALN 84.268 Federal Direct Student Loans Program Criteria: Students who receive federal student aid are required to be enrolled in an eligible program. Eligible programs must be included in an institution’s ac...

2023-001 Program Eligibility—Significant Deficiency United States Department of Education - ALN 84.268 Federal Direct Student Loans Program Criteria: Students who receive federal student aid are required to be enrolled in an eligible program. Eligible programs must be included in an institution’s accreditation and authorized by the State and the US Department of Education. Condition: The Law School disbursed federal student aid to 63 students, totaling approximately $2,115,747, enrolled in an ineligible program; the LL.M. program. Context: The impact was to 63 students over a four-year period. Cause: The Master of Laws (LL.M) Program was included in the Law School’s ECAR which was approved by the Department of Education. The Law School’s accreditation by the American Bar Association does not cover programs outside of the Juris Doctorate program. As such, the LL.M program was not properly accredited and therefore not an eligible program. The ECAR was subsequently amended to remove this program. Effect: Federal student aid funds were inappropriately disbursed to students in an ineligible program which resulted in the Law School entering into a settlement agreement with the U.S. Department of Education pursuant to which the Law School reimbursed and paid a fine to the US Department of Education. Questioned Costs: $2,115,747 Recommendation: We recommend the Law School review new or modified programs to ensure program eligibility requirements are met. Corrective Actions Taken: Upon notification from Department of Education regarding this concern, the Law School discontinued disbursement of Title IV funds to students of the LL.M. program and will not disburse those funds to students of that program until it receives additional accreditation. The Law School is currently working on obtaining accreditation from the Middle States Commission on Higher Education for its existing LL.M. and future Master’s degree programs. Responsible Person: David D. Meyer, President and Dean, (718) 780-7901, david.meyer@brooklaw.edu

View Audit 300177 Questioned Costs: $1

Finding 388452 (2023-002)

Significant Deficiency 2023

Colorado Mountain College

CO

Questioned Costs Student Financial Aid Subrecipient Monitoring § 200.303

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Reco...

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: CLA recommends that the College review the requirement and implement a monitoring control to monitor the checks throughout the year. In addition, for the checks outstanding greater than 240 days, the College should return the funding to the U.S. Department of Education. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To enhance the 240 Day Outstanding refund check processing efficiency and compliance, a streamlined procedure was developed and implemented to monitor all uncashed refund checks, including those from federal aid sources. This process will involve utilizing an Informer report every two weeks to compile a comprehensive list of uncashed refund checks for current and prior terms. Upon identification, a system-generated communication will be promptly dispatched to students, notifying them of the outstanding refund check and providing clear instructions to contact the Business Office. Calculations will be performed to ascertain if the refund originates from a federal aid source. For students with federal aid-related outstanding refunds, outreach efforts will be undertaken. Additionally, a progressive maintained cumulative report will serve as a real-time monitoring mechanism to track the status of refunds and ensure timely compliance. Continuous open communication will be maintained with the Financial Aid and Compliance team, facilitating the provision of student refunds requiring action and fostering collaboration across departments to address any outstanding issues effectively. The above-detailed process has already proven effective and noticeably successful in addressing the challenges associated with uncashed refund checks, particularly those originating from federal aid sources. Moving forward, this process will be continuously optimized and refined as system enhancements allow. Regular evaluations will be conducted to identify areas for improvement and implement necessary adjustments, ensuring that the refund processing workflow remains efficient, compliant, and responsive to the evolving needs of both students and regulatory requirements. This commitment to ongoing optimization underscores our dedication to providing timely and accurate refunds while upholding the highest standards of financial stewardship and accountability. Name(s) of the contact person(s) responsible for corrective action: Renee McBride Planned completion date for corrective action plan: January 2024

View Audit 300168 Questioned Costs: $1

Finding 388448 (2023-001)

Significant Deficiency 2023

Colorado Mountain College

CO

Student Financial Aid Matching / Level of Effort / Earmarking Questioned Costs § 200.303

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Reco...

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the college reevaluate their procedures regarding the return of Title IV funds including the implementation of secondary review of calculations. This would prevent future errors, and provide a greater level of internal control. Additionally, we recommend they review policies regarding the timeliness and accuracy of student enrollment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CMC established a new secondary review procedure to help prevent future errors and provide a greater level of internal control regarding the return of Title IV funds (R2T4). Going forward, after an R2T4 is completed, the Quality Assurance (QA) review will be processed. As part of this review, the Financial Aid and Scholarship Coordinator will be notified that all R2T4’s have been completed for the current week. They will then pull up the spreadsheet of students who had an R2T4 completed and select at random at least 10% of the students on that list to review. In this review they will examine the following data for each of the selected students:  Each class for that semester including the name of the class, the dates the class took place, the credit load of the class, the last date of attendance (LDA) for each class, if the class counts towards the program, if the class was marked as never attended, and if the class should be used in the R2T4.  The Institutional charges to ensure the correct charges were used.  The Days attended vs Total days to ensure that any break of 5 or more days was removed. To document the review, the Financial Aid and Scholarship Coordinator will initial next to each class that they check as they review. The Financial Aid and Scholarship Coordinator will also review that the awards were updated in the Colleague AIDE screen correctly based on the calculation and ensure that any Post-Withdrawal Disbursement (PWD) or return is processed accurately. They will also verify that the Exit counseling request was sent to the student (this is indicated in the CRI screen). Once the review is completed, the Financial Aid and Scholarship Coordinator will initial and date the spreadsheet for the student that they performed the review on. They will then change the color on the spreadsheet tab to indicate that it was reviewed. Name(s) of the contact person(s) responsible for corrective action: Reilly Watanabe, JoAnna Hulett and Janelle Cook Planned completion date for corrective action plan: July 2023

View Audit 300168 Questioned Costs: $1

Finding 388430 (2023-009)

Significant Deficiency 2023

State of Hawaii, Department of Accounting and General Services

HI

Questioned Costs Eligibility Significant Deficiency

Finding No. 2023‐009 – Eligibility (Significant Deficiency) State Department of Labor and Industrial Relations AL Number: 17.225 Program Title: Unemployment Insurance Condition The audit identified two payments where the recipients did not make the minimum number of work search contacts. Current Sta...

Finding No. 2023‐009 – Eligibility (Significant Deficiency) State Department of Labor and Industrial Relations AL Number: 17.225 Program Title: Unemployment Insurance Condition The audit identified two payments where the recipients did not make the minimum number of work search contacts. Current Status of Corrective Action Plan Concur. Hawaii UI issued a memo, dated September 22, 2023, reminding the local offices of the minimum work search requirements under Administrative Rule 12‐5‐35(c) and for the adjudication unit to conduct a fact‐finding as to the reasons for the claimant’s non‐compliance. Hawaii UI is currently working on a project to enhance the work search process and requirements using a grant awarded to UI by US Department of Labor. The project will allow expansion to the work search reporting requirement on the front‐end of the online weekly claim certification process to include employer job search details. The process entails the use of Behavioral Insight techniques to encourage accurate reporting of the work search requirement and provide a log of their work search efforts. These enhancements will help claimants better understand UI program requirements including: -What claimants should report and why, -The reporting expectations at various decision points throughout the certification process while they still have time to meet the requirements, -Convey the consequences of intentionally providing false information or making mistakes during reporting, and -Imposing a denial of benefits for weeks in which the claimant does not meet the work search eligibility requirement. Person Responsible Sheryl Maligro, UI Program Supervisor Anticipated Date of Completion The enhancements to the Work Search Process are anticipated to be completed in June 2024.

View Audit 300162 Questioned Costs: $1

Finding 388425 (2023-001)

Material Weakness 2023

Christus Health

TX

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles

Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...

Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2023 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.

View Audit 300159 Questioned Costs: $1

Finding 388424 (2023-002)

Significant Deficiency 2023

Catholic Community Services of Southern Arizona, Inc.

AZ

Questioned Costs Subrecipient Monitoring Significant Deficiency

Secondary Review of Billings (Significant Deficiency) Federal Agency: U.S. Department of Health and Human Services Program Title: Child Care and Development Block Grant Assistance Listing Number: 93.575 Federal Award Source: Pass-Through Funding Pass-Through Entity: Arizona Department of Economic S...

Secondary Review of Billings (Significant Deficiency) Federal Agency: U.S. Department of Health and Human Services Program Title: Child Care and Development Block Grant Assistance Listing Number: 93.575 Federal Award Source: Pass-Through Funding Pass-Through Entity: Arizona Department of Economic Security Pass-Through Identifying Number: SX222367 Criteria – Section §200.303 of the Uniform Guidance states that a non-Federal entity must 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. Condition and Context – During our audit of allowable activities, we noted the Organization did not conduct a secondary internal supervisory review of the monthly billings for this program prior to submission to the funding source. Cause and Effect – Due to a shortage in staff, all 12 monthly billings for this program were prepared by one individual and were not reviewed and approved by secondary supervisory personnel. Questioned Costs – None identified. Recommendation – We recommend that the Organization improve its internal controls over the preparation of billings for this program to ensure all billings are reviewed and approved by secondary supervisory personnel. View of Responsible Officials: We agree with the finding. We have implemented procedures to ensure secondary reviews of all billings. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: CCS will improve its internal controls over the preparation of all billings. Effective April 1, 2024, Tammy Gallegos, CCS Accounting Manager, will make certain all billings are reviewed and approved by a secondary supervisor. The Accounting Manager will check off and sign off on a listing of all billings in an effort to ensure and document that 1) the billings were reviewed by a secondary supervisor, 2) the billings were submitted to the payers, and 3) the billings were submitted on a timely manner.

View Audit 300150

Finding 388423 (2023-001)

Significant Deficiency 2023

Catholic Community Services of Southern Arizona, Inc.

AZ

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

Procurement (Significant Deficiency) and Compliance Federal Agency: U.S. Department of Homeland Security Program Title: Emergency Food & Shelter National Board Program (“EFSP”) Assistance Listing Number: 97.024 Federal Award Source: Pass-Through Funding Pass-Through Entity: Pima County Pass-Through...

Procurement (Significant Deficiency) and Compliance Federal Agency: U.S. Department of Homeland Security Program Title: Emergency Food & Shelter National Board Program (“EFSP”) Assistance Listing Number: 97.024 Federal Award Source: Pass-Through Funding Pass-Through Entity: Pima County Pass-Through Identifying Number: CT-GMI-21-452 Criteria – Section §200.320 of the Uniform Guidance requires that when the value of the procurement for property or services under a Federal financial assistance award exceeds the Simplified Acquisition Threshold, a formal procurement method is required, such as a sealed bid or proposal. In addition, these formal procurement methods require public advertising. Condition – During our audit of the procurement requirements for the EFSP program, we noted the Organization utilized a vendor who in total was paid more than the Simplified Acquisition Threshold; however, the Organization did not utilize a formal procurement method in selecting this vendor as required by their policies and the Uniform Guidance. Cause – The finding appears to be the result of an immediate need to obtain services and an oversight to subsequently conduct a formal procurement method. Effect and Context – By not adhering to a formal procurement method, the Organization may or may not have chosen the best vendor to provide the services. There was only one vendor whose payments exceeded the Simplified Acquisition Threshold during the audit period. Our sample was a statistically valid sample. Questioned Costs – None identified. Recommendation – We recommend the Organization provide periodic training to its program staff regarding procurement requirements per the Uniform Guidance and consider modifying its procurement related internal controls to ensure all staff follow the Organization’s procurement policies. View of Responsible Officials: We are in agreement with the finding and are in the process of updating our procedures to mitigate issues in the future. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: CCS has updated its purchasing policy as of March 22, 2024. The purchasing policy will be included as part of the program staff’s required 2024 annual training effective April 1, 2024. The Relias Learning platform will be the mechanism used for this training. Staff will be given a deadline of April 30, 2024 to complete this training. In addition, Tammy Gallegos, the CCS Accounting Manager will monitor large purchases by vendor on a monthly basis. This is to ensure that vendors providing goods or services to CCS that meet or exceed the Single Acquisition Threshold per federal regulations follow a formal procurement method, such as soliciting bids. Bids will be kept with the vendors’ file in the CCS Business Office.

View Audit 300150

Finding 388413 (2023-103)

Material Weakness 2023

Santa Cruz County

AZ

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.303

Assistance Listings number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Contact Person(s): Mauricio A. Chavez, Deputy County Manager/CFO Anticipated completion date: April 30, 2024 The County’s finance department reported the entirety of the allo...

Assistance Listings number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Contact Person(s): Mauricio A. Chavez, Deputy County Manager/CFO Anticipated completion date: April 30, 2024 The County’s finance department reported the entirety of the allocation based on County’s interpretation of the final rule and multiple subsequent reporting guidelines. The County will revise and resubmit reports to the Treasury Department and will work with staff to correct any deficiencies for future reports. The County will meet with staff to assess all present and future grant reporting guidelines.

View Audit 300146

Finding 388410 (2023-101)

Material Weakness 2023

Santa Cruz County

AZ

Matching / Level of Effort / Earmarking Questioned Costs § 200.303

Assistance Listings number and program name: 17.259 WIOA Youth Activities Contact Person(s): Irasema Olvera, WIOA Director Anticipated completion date: June 30, 2025 To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County continues to d...

Assistance Listings number and program name: 17.259 WIOA Youth Activities Contact Person(s): Irasema Olvera, WIOA Director Anticipated completion date: June 30, 2025 To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County continues to develop written policies and procedures for its WIOA Youth Activities program. The County continues to provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The County will also work with the pass-through grantor to develop an effective strategy to recruit and retain eligible out-of-school youth. Through the pass-thru grantor, the County requested a waiver of the of the 75% out-of-school youth program earmark ultimately seeking a more balanced 50% for the out-of-school youth program and 50% for the in-school youth program distribution. The County will continue to monitor the out-of-school services spending throughout the fiscal year and award period.

View Audit 300146 Questioned Costs: $1

Finding 388408 (2023-004)

Material Weakness 2023

City of Atlanta

GA

Questioned Costs Allowable Costs / Cost Principles Reporting

Name of Contact Person Responsible for Corrective Action Plan: Jerry Deloach, Chief Risk Officer - Enterprise Risk Management Corrective Action Plan: The City of Atlanta’s Department of Enterprise Risk Management (ERM) is now calendaring the quarterly reports due dates and immediately following the ...

Name of Contact Person Responsible for Corrective Action Plan: Jerry Deloach, Chief Risk Officer - Enterprise Risk Management Corrective Action Plan: The City of Atlanta’s Department of Enterprise Risk Management (ERM) is now calendaring the quarterly reports due dates and immediately following the timely filing before transmitting a copy of the report to the City of Atlanta’s Grants Accounting area. Anticipated Completion Date: Fiscal year 2024

View Audit 300142

Finding 388399 (2023-001)

Significant Deficiency 2023

Heidelberg University

OH

Questioned Costs Student Financial Aid Special Tests & Provisions

The academic calendar used for return of funds calculations will be reviewed by a separate individual in the Financial Aid Office. We will review each calculation as it is completed to verify that the number of days in the semester have been reported correctly for each student.

View Audit 300140 Questioned Costs: $1

Finding 388363 (2023-010)

Material Weakness 2023

County of Los Angeles

CA

Period of Performance Questioned Costs Allowable Costs / Cost Principles § 200.1 § 200.211 § 200.403

1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. The County will review CSLFRF claims and verify that all claimed payroll expenditures were incurred or obligated on or after March 3, 202...

1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. The County will review CSLFRF claims and verify that all claimed payroll expenditures were incurred or obligated on or after March 3, 2021. Payroll expenditures that were incurred or obligated before March 3, 2021, will be removed from the CSLFRF claims. 3. Anticipated implementation date: June 28, 2024

View Audit 300135 Questioned Costs: $1

Finding 388349 (2023-007)

Material Weakness 2023

Department of Education, State of Hawaii

HI

Questioned Costs Special Tests & Provisions Material Weakness

2023-007 Special Tests and Provisions – Material Weakness View of Responsible Officials Management agrees with the findings and recommendations. Corrective Action Plan The audit finding was due in large part to a vacancy in the Department ESSER grant support position that arose in the first qua...

2023-007 Special Tests and Provisions – Material Weakness View of Responsible Officials Management agrees with the findings and recommendations. Corrective Action Plan The audit finding was due in large part to a vacancy in the Department ESSER grant support position that arose in the first quarter of the fiscal year, which contributed to the breakdown in construction project tracking. The Department hired a replacement for this grant support position in the second quarter of the fiscal year, and during the third quarter hired a second grant support position to ensure enhanced support capacity and continuity. These two individuals continue to comprise the ESSER Grant Management Office (team) and in the fourth quarter of the fiscal year initiated a process to document school and complex area use of ESSER funds for construction purposes. The team held a department-wide informational webinar in partnership with the Department’s Office of Facilities and Operations on May 22, 2023. The webinar agenda included the newly implemented pre-approval construction application process and federal requirements pursuant to Title 2, Section 200, Appendix II, of the Code of Federal Regulations (CFR). The team will continue to work with the Department’s Complex Area Staff to reiterate the award requirements and examine construction-related contracts over $2,000 to verify compliance with the award requirements. Contact Person: Brian Hallett Assistant Superintendent and CFO Office of Fiscal Services Anticipated Completion Date: June 30, 2024

View Audit 300126

Finding 388347 (2023-005)

None 2023

Department of Education, State of Hawaii

HI

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

2023-005 Special Tests and Provisions – Control Deficiency View of Responsible Officials Management agrees with the finding and recommendation. The Department is currently in the process of hiring personnel to assist with providing services. Corrective Action Plan Migrant Education Program lea...

2023-005 Special Tests and Provisions – Control Deficiency View of Responsible Officials Management agrees with the finding and recommendation. The Department is currently in the process of hiring personnel to assist with providing services. Corrective Action Plan Migrant Education Program leadership will review the criteria identified in the Title I, Part C, Section 1304 of the Every Student Succeeds Act, which requires the Department to give priority services to officially identified Priority for Service designated students. Program leadership will ensure that personnel are familiar with all grant requirements and retain necessary documentation to comply with federal program requirements. A statewide memo will be distributed to include: • A summary about the identification process for determining who are Migrant Education students and the state program database that tracks this information. • Review of all Federal and State education obligations to service Migrant Education students. • Include a list of potential support services and resources to service Migrant Education students. • Information will be added to the Leadership Bulletin to help inform and remind leaders about the state’s obligations to support Migrant Education students. • Additional dissemination of this information will be shared by Assistant Superintendent Kalama to all Complex Area Superintendents. Contact Person: Bruce Kawachika, State Migrant Education Program Manager Student Services Branch English Learner/Migrant Education Section Office of Student Support Services Anticipated Completion Date: December 31, 2024

View Audit 300126

Finding 388346 (2023-004)

None 2023

Department of Education, State of Hawaii

HI

Internal Control / Segregation of Duties Questioned Costs Eligibility § 200.403

2023-004 Student Eligibility – Control Deficiency View of Responsible Officials Management agrees with the finding and provides more context regarding the finding. Participant eligibility procedures are based on USC §3272 and §3102 were created for Adult Education Family Literacy Act (AEFLA)-fun...

2023-004 Student Eligibility – Control Deficiency View of Responsible Officials Management agrees with the finding and provides more context regarding the finding. Participant eligibility procedures are based on USC §3272 and §3102 were created for Adult Education Family Literacy Act (AEFLA)-funded adult schools. The procedures were distributed, and training was provided on March 31, 2023 to address prior audit Finding No. 2022-03. The enrollment record that did not meet the criteria for eligibility in the Single Audit Fiscal Year Ending 06/30/23 had an intake date of September 15, 2022, approximately six months before the procedures were distributed and training provided. A corrective action has already taken place through the March 31, 2023 procedures distribution and training. The AEFLA-funded adult schools are aware that all participants reported in the AEFLA reporting system, known as the National Reporting System, including participants in workplace adult education and literacy activities as defined in United States Code, Title 29, Chapter 32 Workforce Innovation and Opportunity Act §3272, must meet AEFLA eligibility requirements. Corrective Action Plan Participant eligibility procedures for AEFLA-funded adult schools based on USC §3272 and §3102 will be reviewed annually with AEFLA-funded adult schools through a technical assistance session. The procedures inform the staff of the AEFLA-funded adult school of the following: • The Workforce Innovation and Opportunity Act • The Adult Education and Family Literacy Act • The relevant US Code and Code of Federal Regulations • A definition of AEFLA-eligible individuals • Categories of funding and their purpose • The role of the US DOE Office of Career Technical and Adult Education • The role of the Hawaii state director for adult education • The role of the AEFLA-funded local service providers Contact Person: Dan Miyamoto, TA Community Education Specialist Curriculum Innovation Branch Office of Curriculum and Instructional Design Anticipated Completion Date: August 31, 2024

View Audit 300126

Finding 388344 (2023-003)

None 2023

Department of Education, State of Hawaii

HI

Questioned Costs Cash Management Period of Performance § 200.344

2023-003 Cash Management / Period of Performance – Control Deficiency View of Responsible Officials Management appreciates the opportunity to respond to the findings of the audit. The Hawaii State Public Library System (HSPLS) makes every attempt to meet all federal laws and guidelines for fundin...

2023-003 Cash Management / Period of Performance – Control Deficiency View of Responsible Officials Management appreciates the opportunity to respond to the findings of the audit. The Hawaii State Public Library System (HSPLS) makes every attempt to meet all federal laws and guidelines for funding that is received. Many factors outside our control directly impacted the timely payment of vendors as noted in the audit. Specifically: 1) Federal budget uncertainty; delay in receiving federal funding. For the past several years, Congress has not been able to pass a comprehensive federal budget, and instead has funded the Grants to States fund via continuing resolutions making it difficult to plan out expenditures with any certainty. In addition to lacking the certainty of when and/or if funding will be available, the Grants to States funds have not been released to states in a timely manner, including during the audit period. Instead of at the beginning of the federal fiscal year around October 1st, funding has been received months later, leaving States with a lot less time to procure, process and receive purchases. This means we do not have access to the funding for the full grant cycle and directly impacts if/when we are able to procure goods and services. 2) Supply chain and shipping issues. The State of Hawaii procurement requirements do not allow us to pay for goods and services until we receive the products or the services are rendered satisfactorily. HSPLS continues to face significant supply chain and shipping issues which affects the timely payment of vendors. As an island state in the middle of the Pacific Ocean, there are often delays in receiving an entire shipment on time in full, even post-pandemic. For large products or orders, sometimes the order and/or related parts are not shipped together further delaying completion of the order by the vendor and issuance of the invoice. In many instances, vendors do not send their invoices in a timely manner, preventing HSPLS from dispersing funds in a timely manner. 3) Federal agency guidance. We would also like to note that in the past, we have contacted our funding federal agency and let them know that we have had challenges with supply chain and shipping issues. We were advised that it was understood, and that as long as we had encumbered the funds by September 30, that we would be able to use the funding that was allotted to us even if the invoice is received after the close of the federal fiscal year. Corrective Action Plan We will do our best to continue to monitor and minimize any untimely disbursements of federal funds. Contact Person: Stacy A. Aldrich State Librarian Hawaii State Public Library System Anticipated Completion Date: Ongoing

View Audit 300126

Finding 388343 (2023-002)

Material Weakness 2023

Department of Education, State of Hawaii

HI

Questioned Costs Subrecipient Monitoring Material Weakness

2023-002 Reporting – Material Weakness View of Responsible Officials Administration agrees with the findings and recommendations. Corrective Action Plan The Office of Monitoring and Compliance (MAC) will provide training to recipients when funds are allocated within the Department. The Policy, ...

2023-002 Reporting – Material Weakness View of Responsible Officials Administration agrees with the findings and recommendations. Corrective Action Plan The Office of Monitoring and Compliance (MAC) will provide training to recipients when funds are allocated within the Department. The Policy, Innovation, Planning and Evaluation Branch (PIPE) will communicate with the Office of Fiscal Services and MAC on a semi-annual basis to start the reporting process on December 1 and June 1 of each year to meet the January 31 and July 31 respective deadlines. Additionally, PIPE has identified a dedicated staff member who will spearhead the administration of this grant to ensure that any changes in the reporting requirements as defined in the OIA Cooperative Agreement will be quickly identified and followed. Contact Persons: Ken Kakesako, Director Policy, Innovation, Planning and Evaluation Branch Office of Strategy Innovation and Performance Jacy Yamamoto, Interim Director Office of Monitoring and Compliance Office of the Deputy Superintendent Anticipated Completion Date: June 1, 2024

View Audit 300126

Finding 388336 (2023-008)

Material Weakness 2023

State of Hawaii Department of Health

HI

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking

Level of Effort Maintenance of Effort requirement was not met. Corrective Action Plan: AMHD and CAMHD have been in discussion with SAMHSA for the last few months about meeting the maintenance of effort requirement. This issue has not been resolved. Implementation Date: July 1, 2024 Responding Offici...

Level of Effort Maintenance of Effort requirement was not met. Corrective Action Plan: AMHD and CAMHD have been in discussion with SAMHSA for the last few months about meeting the maintenance of effort requirement. This issue has not been resolved. Implementation Date: July 1, 2024 Responding Official: Courtenay Matsu, MD, Acting Administrator, Adult Mental Health Division

View Audit 300124

Finding 388328 (2023-002)

Significant Deficiency 2023

Memorial Hospital of Laramie County D/b/a Cheyenne Regional Medical Ce

WY

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: The Medical Center was not able to provide supporting invoices for t...

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: The Medical Center was not able to provide supporting invoices for two of the testing selections. An additional selection contained a keying error. Responsible Individuals: Amy Spieker, Director Community Health and Analysis, and Erika Novick, Operations Manager Corrective Action Plan: The Program Director and Operations Manager will ensure all invoices are properly submitted and approved prior to including the expenses in the reimbursement requests. Program Director/Director of Community Health and Analysis will review draws/invoices to ensure amounts on supporting documents agree to the amounts submitted in the reimbursement requests. Finance will also revise Corporate Card Policy by June 30, 2024, to include expense reports being submitted in a timely manner. Finance will review open expense reports with card holder and their supervisor monthly. Anticipated Completion Date: April 1, 2024

View Audit 300118

Finding 388327 (2023-001)

Significant Deficiency 2023

Memorial Hospital of Laramie County D/b/a Cheyenne Regional Medical Ce

WY

Questioned Costs Reporting Significant Deficiency § 200.303

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: There was no evidence retained that the Medical Center’s compliance ...

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: There was no evidence retained that the Medical Center’s compliance reports submitted to Equal Justice and Wyoming Department of Family Services (WDFS) were reviewed and approved prior to submission. Responsible Individuals: Amy Spieker, Director Community Health and Analysis Corrective Action Plan: The Program Director will review and approve the data input into the monthly and quarterly reports. If red flags are identified, adjustments will be made. Once the reports are deemed satisfactory, the Program Director will electronically sign off on the report to denote review and approval for submission to awarding agency. Anticipated Completion Date: April 1, 2024

View Audit 300118

Finding 388300 (2023-001)

Significant Deficiency 2023

Santa Barbara Community College District

CA

Subrecipient Monitoring Eligibility Questioned Costs

Response Two different sets of guidelines were issued for the Coronavirus State and Local Fiscal Recovery Funds. The first set of guidelines were issued in March 2021 (Attachment A). These first set of guidelines allowed undocumented students to receive the award #4 (Attachment A). These are the g...

Response Two different sets of guidelines were issued for the Coronavirus State and Local Fiscal Recovery Funds. The first set of guidelines were issued in March 2021 (Attachment A). These first set of guidelines allowed undocumented students to receive the award #4 (Attachment A). These are the guidelines that were used to award students monies from this fund. During the audit, it was noted that SBCC incorrectly awarded undocumented students with monies from the Coronavirus State and Local Fiscal Recovery Funds. SBCC was not aware at the time of awarding these monies that a second guidance memo had been issued by the Community Colleges of California Chancellor’s Office (CCCCO) on Friday, January 21,2022 (Attachment B). The updated memo clearly stated that undocumented students were no longer eligible for these funds. SBCC had not updated its protocols to match the second memo due to staffing issues within th e financial aid office. Specifically, the manager of the Financial Aid Office was out on disability leave from January 26 through September 28, 2022. However, no funds were awarded during this absence. Within the new guidance, a new process stated how to corrects awards given to candidates originally eligible (undocumented students) under the first memo, but no longer eligible under the second memo. Per the second memo, any incorrectly awarded funds under the first policy were to be replaced with other funds that undocumented students are eligible to receive. Corrective Action To correct the incorrect awarding of funds to ineligible candidates, SBCC cancelled the awards to now ineligible recipients of Early Action Fund (EMASS/SRFR) and replace d them with awards from AB19 monies, which were rolled over from 22-23. SBCC also used monies from remaining HEERF/CARES funds, which allowed for awards to undocumented students. In total, SBCC corrected 16 awards totaling $48,000. SBCC’s records now reflect that no undocumented students received Coronavirus State and Local Fiscal Recovery Funds. Going forward, SBCC is now awarding under the correct guidelines. No further awards have been made to undocumented students. The fund is winding down and will be spent in full by the end of the 23-24 fiscal year.

View Audit 300097 Questioned Costs: $1

Finding 388299 (2023-001)

Significant Deficiency 2023

Jobpath, Inc.

AZ

Questioned Costs Subrecipient Monitoring Reporting

Reporting (Significant Deficiency) and Federal Agency: U.S. Department of Treasury Program Title: Coronavirus State and Local Fiscal Recovery Funds (“CSLFRF”) Assistance Listing Number: 21.027 Federal Award Source: Pass-Through Funding Pass-Through Entity: State of Arizona Pass-Through Identifying...

Reporting (Significant Deficiency) and Federal Agency: U.S. Department of Treasury Program Title: Coronavirus State and Local Fiscal Recovery Funds (“CSLFRF”) Assistance Listing Number: 21.027 Federal Award Source: Pass-Through Funding Pass-Through Entity: State of Arizona Pass-Through Identifying Number: GR-ARPA-JP-030122-01 Criteria – The pass-through entity’s grant agreement with the Organization requires that the Organization submit quarterly summary reports with the numbers of program participants no later than 15th of the month following each Fiscal Quarter. Condition – During our audit of the reporting requirements for the CSLFRF program, we requested quarterly summary reports and noted that they were not created nor submitted. Cause – The finding appears to be the result of staffing turnover at the Organization. The former Grants Manager resigned in May 2023 with position being absorbed by Director of Finance in July 2023. Effect and Context – Four quarterly summary reports were not submitted. Questioned Costs – None identified. Recommendation – We recommend the Organization implement policies and procedures to ensure timely and accurate reporting of required program reports. View of Responsible Officials: We are in agreement with the finding and are in the process of updating our procedures to mitigate the issues noted in the future. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: The Director of Finance will create a grant reporting checklist so that in the event of staff turnover, no reporting requirements are overlooked in the transition. The checklist will be created by the next quarterly grants meeting scheduled for April 4th. Subsequently, the Director of Finance will update the checklist every time a new grant is received and include a status review of all grant reporting requirements in the weekly Finance meeting and quarterly Grant meeting agendas, both of which are attended by the CEO, Director of Operations, Director of Development, and Director of Finance.

View Audit 300092

Finding 388298 (2023-001)

Significant Deficiency 2023

City of San Buenaventura

CA

Questioned Costs Subrecipient Monitoring Reporting

The City program leads responsible for specific grants will read the compliance requirements related to those grants prior to commencement. They will then work with Finance and Accounting to determine what the compliance requirements are along with the related deadlines. Additionally, they will also...

The City program leads responsible for specific grants will read the compliance requirements related to those grants prior to commencement. They will then work with Finance and Accounting to determine what the compliance requirements are along with the related deadlines. Additionally, they will also determine who is responsible for each compliance requirement and monitor the grant from commencement to completion to ensure each of those requirements are being complied with by the responsible parties and by the related deadlines.

View Audit 300090

Corrective Action Plans

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