Corrective Action Plans

Finding 555380 (2024-003)

None 2024

Tulsa Public Schools/independent School District No. I-1

OK

Reporting Procurement, Suspension & Debarment § 200.512

Tulsa Public Schools concurs with the finding regarding the late submission of the Single Audit package for the fiscal year ended June 30, 2024. The delay was due to the district's external auditors requesting additional time to complete extended testing and audit procedures prompted by the findings...

Tulsa Public Schools concurs with the finding regarding the late submission of the Single Audit package for the fiscal year ended June 30, 2024. The delay was due to the district's external auditors requesting additional time to complete extended testing and audit procedures prompted by the findings in the Oklahoma State Auditor and Inspector (OSAI) report. While this situation was outside the district’s direct control, the district recognizes the importance of timely federal reporting and is implementing a corrective strategy to mitigate future risks of noncompliance. Going forward, the district will revise its audit readiness timeline to account for possible additional audit procedures or investigative follow-up. The Director of Accounting will coordinate more proactively with external auditors to communicate any potential delays and ensure resource availability for timely completion. The district is committed to submitting its FY2025 Single Audit package on or before the required deadline and ensuring continued transparency in its federal compliance reporting. Tulsa Public Schools is committed to full compliance and confirms that the FY2024 Single Audit package will be submitted to the Federal Audit Clearinghouse no later than April 30, 2025. Owner: Vonnita Edwards, Financial Reporting Manager

View Audit 354002

Finding 555345 (2024-002)

Material Weakness 2024

Newhall School District

CA

Subrecipient Monitoring Material Weakness Reporting

Corrective Action Plan and Views of Responsible Officials Views of Responsible Officials The District acknowledges the audit finding regarding insufficient retention of financial records supporting the annual ESSER expenditure reports submitted to the California Department of Education. We understan...

Corrective Action Plan and Views of Responsible Officials Views of Responsible Officials The District acknowledges the audit finding regarding insufficient retention of financial records supporting the annual ESSER expenditure reports submitted to the California Department of Education. We understand that maintaining accurate and accessible documentation is essential to federal compliance under Title 2, Code of Federal Regulations (CFR) §200.334. The District takes full responsibility for this oversight and is taking immediate steps to strengthen its internal controls and documentation practices. Corrective Action Plan 1. Reason for the Finding: This issue arose due to high turnover in the position responsible for federal reporting. As a result, institutional knowledge and documentation practices were disrupted, making it difficult to locate supporting financial records for the annual ESSER expenditure report. While the quarterly reports submitted throughout the year were accurate and properly supported, the annual report was not fully aligned with available documentation due to incomplete record retention during the staffing transitions. 2. Actions to be Taken to Correct the Issue: Centralized Document Management System: The District will implement a centralized, secure electronic document management system (e.g., Google Drive, SharePoint, or a financial records database) specifically for tracking and retaining federal program documentation. All financial records supporting ESSER and similar federal grants will be stored here and categorized by funding source, fiscal year, and reporting period. Standard Operating Procedure (SOP): A formal SOP for federal grants management will be created and distributed to all relevant departments. This will include clear guidelines for documentation, record retention timelines, and roles/responsibilities for financial reconciliation and audit readiness. Staff Training: District staff responsible for federal program management and reporting will be trained on the new SOP, federal compliance regulations (including CFR §200.334), and the use of the document management system. Refresher trainings will be conducted annually or as needed. Pre-Submission Review: A dual review process will be instituted where both the Business Services and Federal Programs teams confirm the availability and accuracy of supporting documentation before any reports are submitted to oversight agencies. 3. Timeline for Implementation: All corrective actions will be in place within 90 days. The centralized document storage system and SOPs will be finalized and rolled out within 60 days. Staff training will be completed within the following 30 days. Immediate measures to retain ESSER documentation have already been initiated.

View Audit 353992

Finding 555343 (2024-002)

Material Weakness 2024

California State University

CA

Reporting § 200.303 § 200.502 § 200.510

The University concurs with the recommendation. The University will review and enhance its procedures and internal controls to ensure the SEFA is complete and accurate

View Audit 353990

Finding 555342 (2024-001)

Material Weakness 2024

California State University

CA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The University concurs with the recommendation. The University will further review and refine the policies and procedures to strengthen internal controls and to ensure the timely and accurate reporting to NSLDS.

View Audit 353990

Finding 555341 (2024-004)

Significant Deficiency 2024

City of American Canyon

CA

Reporting

Finding 2024-004 – Schedule of Expenditures of Federal Awards (SEFA) – Significant Deficiency The errors in the SEFA, including incorrect pass-through grants and outdated grant numbers, have been corrected, and a review process is now in place before the audit, with a second check for accuracy. The ...

Finding 2024-004 – Schedule of Expenditures of Federal Awards (SEFA) – Significant Deficiency The errors in the SEFA, including incorrect pass-through grants and outdated grant numbers, have been corrected, and a review process is now in place before the audit, with a second check for accuracy. The Senior Accountant will prepare the SEFA, and the Finance Manager will review it to ensure accuracy. We will communicate with granting agencies to confirm whether grants are federal and use a checklist to ensure proper classifications. Moving forward, federal and state grants will be correctly recorded, grants will be properly classified when recorded in the general ledger, and annual training on SEFA preparation and Uniform Guidance compliance will be provided.

View Audit 353989

Finding 555327 (2024-002)

Significant Deficiency 2024

Serenity House Counseling Services, Inc.

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Procedures for maintaining accurate accounts receivable records will be reinforced, including periodic review. Beginning June 1, 2025, we will implement steps and procedures to eliminate the tardiness of Data Collection in Federal Audit Clearinghouse.

View Audit 353974

Finding 555326 (2024-002)

None 2024

United Mental Health & Addiction Recovery Coalition

IL

Reporting Internal Control / Segregation of Duties § 200.327

Auditee Response: Management concurs with the finding. A new financial reporting calendar has been implemented and distributed to all staff. A formal review and approval process for financial reports has been implemented. The report for the quarter ended June 2024 will be submitted by end of March 2...

Auditee Response: Management concurs with the finding. A new financial reporting calendar has been implemented and distributed to all staff. A formal review and approval process for financial reports has been implemented. The report for the quarter ended June 2024 will be submitted by end of March 2025.

View Audit 353963

Finding 555313 (2024-001)

Significant Deficiency 2024

Humility of Mary Housing, Inc.

OH

Reporting

Recommendation: We recommend that the Organization electronically file their reporting package, including the audited financial statements, to the Federal Audit Clearinghouse by the due date or request an extension for more time is needed. Response: Management agreed with the recommendation and pla...

Recommendation: We recommend that the Organization electronically file their reporting package, including the audited financial statements, to the Federal Audit Clearinghouse by the due date or request an extension for more time is needed. Response: Management agreed with the recommendation and plans on adhering to the deadline for future submissions.

View Audit 353944

Finding 555296 (2024-001)

Significant Deficiency 2024

Launch Alaska

AK

Reporting

The Organization has implemented improved internal controls and reporting mechanisms to ensure timely submission of reporting packages in accordance with 2 CFR Part 200, Subpart F, Section 200.512. Steps include a compliance calendar, internal reminders, and accountability measures to prevent future...

The Organization has implemented improved internal controls and reporting mechanisms to ensure timely submission of reporting packages in accordance with 2 CFR Part 200, Subpart F, Section 200.512. Steps include a compliance calendar, internal reminders, and accountability measures to prevent future delays.

View Audit 353931

Finding 555238 (2024-002)

Significant Deficiency 2024

Habitat for Humanity of Michigan, Inc.

MI

Reporting Internal Control / Segregation of Duties

Management concurs with the finding and has initiated immediate steps to strengthen record retention and succession planning for federal award management. A key element of our response is the engagement of RDM Associates, our outsourced accounting provider, to ensure compliance with federal regulati...

Management concurs with the finding and has initiated immediate steps to strengthen record retention and succession planning for federal award management. A key element of our response is the engagement of RDM Associates, our outsourced accounting provider, to ensure compliance with federal regulations and establish robust processes. To address this finding, the following actions are underway: By June 30, 2025, management, with the expertise of RDM Associates, will implement a comprehensive record retention policy tailored to federal award management. This policy will outline retention periods, storage protocols, and access requirements, ensuring all documentation is systematically organized and readily available. For fiscal year 2025, RDM Associates is assisting in the creation and retention of adequate reconciling schedules to support all grant draw requests, aligning our processes with federal compliance standards. RDM Associates is also supporting the development of detailed procedure manuals for federal award processes and the implementation of a document management system to centralize and secure critical records. These efforts will mitigate the risks associated with staff turnover and ensure continuity of operations. By June 30, 2025, management will formalize a succession planning process for key positions involved in federal award management, incorporating cross-training of staff under the guidance of RDM Associates to facilitate knowledge transfer and operational resilience. The transition to RDM Associates as our outsourced accounting provider addresses the root causes of this finding by bringing specialized expertise and structured processes to our federal award management. We are confident that these actions will result in sustainable improvements and full compliance with federal requirements. Anticipated completion date for these initiatives is June 30, 2025.

View Audit 353872

Finding 555234 (2024-002)

None 2024

Town of Hartland, Maine

ME

Reporting § 200.512

The Town will put in place a process for more accurate year-end closing and financial statement preparation. Management will work with the auditor to identify and correct the problematic areas.

View Audit 353848

Finding 555223 (2024-004)

Significant Deficiency 2024

Chicago Heights School District 170

IL

Cash Management Reporting Internal Control / Segregation of Duties

The District recognizes the importance of supervisory review in ensuring the accuracy of meal count documentation and reimbursement claims. To address this, the District will implement a standardized review process across all schools requiring supervisory personnel to sign or initial daily meal cou...

The District recognizes the importance of supervisory review in ensuring the accuracy of meal count documentation and reimbursement claims. To address this, the District will implement a standardized review process across all schools requiring supervisory personnel to sign or initial daily meal count sheets. In addition, we will institute a reconciliation step to verify that reported counts align with reimbursement claims. Training will be provided to ensure compliance with these procedures. Anticipated Date of Completion: A review and determination will be completed in fiscal year 2025. Contact Person: Joe Barker, CSBO.

View Audit 353840

Finding 555214 (2024-001)

Significant Deficiency 2024

Spartanburg County First Steps to School Readiness Partnership

SC

Reporting Significant Deficiency

Spartanburg County First Steps (SCFS) management acknowledges its responsibility for complying with all applicable state and federal reporting requirements. SCFS maintains a comprehensive fiscal policies and procedures manual that outlines the responsibilities and processes necessary to ensure compl...

Spartanburg County First Steps (SCFS) management acknowledges its responsibility for complying with all applicable state and federal reporting requirements. SCFS maintains a comprehensive fiscal policies and procedures manual that outlines the responsibilities and processes necessary to ensure compliance with all reporting obligations. The late submission of certain federal reports for the 2023-2024 program year was primarily due to challenges associated with the agency's financial management system, Blackbaud. Specifically, the system generated extended wait times for necessary reports, significantly impacting the agency's ability to meet required deadlines. Over the past six months, SCFS has conducted an extensive evaluation of the Blackbaud system and determined that it does not adequately meet the operational needs of SC First Steps offices across the state. As a result, an emergency procurement process has been initiated to procure a new financial management system that will better support timely and accurate reporting. Spartanburg County First Steps is committed to ensuring all future state and federal reporting requirements are completed and submitted accurately and within required deadlines.

View Audit 353836

Finding 555195 (2024-001)

Significant Deficiency 2024

Feeding San Diego

CA

Reporting

Condition During our audit, CBIZ noted that the Organization did not have adequate internal controls surrounding reception of food boxes, or backpacks provided as some selections did not contain recipient and driver signatures. Views of Responsible Officials: Management agrees with the finding and...

Condition During our audit, CBIZ noted that the Organization did not have adequate internal controls surrounding reception of food boxes, or backpacks provided as some selections did not contain recipient and driver signatures. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: February 7, 2025

View Audit 353821

Finding 555193 (2024-001)

Material Weakness 2024

The Guidance Center, Inc.

AZ

Reporting Material Weakness

Item: 2024-001 Assitance Listing Number: 93.959 Programs: Block Grants for Substance Abuse Prevention, Treatment and Recovery Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Care 1st Compliance Reqauirements: Reporting Criteria of Specific Requireme...

Item: 2024-001 Assitance Listing Number: 93.959 Programs: Block Grants for Substance Abuse Prevention, Treatment and Recovery Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Care 1st Compliance Reqauirements: Reporting Criteria of Specific Requirement: In accordance with the grant agreement, the Organization is required to submit quarterly reports during the grant period which include qualifying costs incurred under the grant award. Condition: A required quarterly report submitted to the granting agency included inaccurate reporting of the qualifying expenditures. Additionally, for all four quarterly reports there was no evidence of management review or approval of the reports prior to submission to the funder. Name of Contact Person: Michael Kuzmin, Chief Financial Officer Phone Number: (928) 714-6478 Anticipated Completion Date: March 31, 2025 Views of Responsible Officials and Corrective Action: Management agrees with the finding and will implement additional controls to ensure expense information included in the quarterly reports in reviewed and approved prior to submission. Management will ensure this additional process includes clearly documenting the review and approval.

View Audit 353812

Finding 555176 (2024-002)

Significant Deficiency 2024

Mary Baldwin University

VA

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

2024-002 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: The University did not report student enrollment data to the National Student Clearinghouse accurately and within minimum required ...

2024-002 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: The University did not report student enrollment data to the National Student Clearinghouse accurately and within minimum required timeframe. Criteria: Based on requirements set forth by 34 CFR 685.309(b)(2), the University is responsible for notifying the National Student Loan Data System (NSLDS) to changes to student’s enrollment data within minimum required timeframes. Cause: The University does not have adequate procedures in place to ensure changes in students’ enrollment statuses are identified and reported in a timely manner. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the student’s loans. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Context: A sample of nine official and unofficial student withdrawals was selected for audit from a population of 63. The test found three student withdrawals that were not in compliance with timely enrollment reporting in NSLDS, the enrollment status for one student was not updated after the student was no longer enrolled on at least a half-time basis, and one student’s enrollment status date reported to NSLDS did not agree to date of withdraw reported on the R2T4 form. Repeat Finding: No. Recommendation: We recommend that the University put procedures in place to ensure that student enrollment statuses are updated in a timely manner. Management Response: The University has modified its withdrawal procedures and instructions related to the requirements set forth by 34 CFR 685.309(b)(2). Related to the findings above, due to staffing turnover, the appropriate test of controls needed to identify changes in a student’s enrollment status was not run in a timely manner. Going forward, the University has informed related staff that the aforementioned test of controls needs to be run at the end of each semester, and upon completion, staff must notify the NSLDS within the required timeframe. If the Federal Audit Clearinghouse has questions regarding this plan, please call Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer at (540) 887-7285. Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer, Mary Baldwin University, 540-887-7285

View Audit 353780

Finding 555175 (2024-001)

Significant Deficiency 2024

Mary Baldwin University

VA

Special Tests & Provisions Student Financial Aid Reporting

2024-001 – Return of Title IV Funds (Significant Deficiency)Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: Return of Title IV funds occurred untimely for three students, exceeding 45 days as required, when considering the University’s ...

2024-001 – Return of Title IV Funds (Significant Deficiency)Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: Return of Title IV funds occurred untimely for three students, exceeding 45 days as required, when considering the University’s date of determination as reported on R2T4 forms. Criteria: Returns of Title IV funds are required to be deposited or transferred into the SFA account or electronic funds transfers initiated to the Department of Education as soon as possible, but no later than 45 days after the date the institution determines that the student withdrew in accordance with 34 CFR 668.173(b). Cause: The University does not have adequate procedures in place to ensure students’ Title IV funds are returned timely. R2T4 forms improperly reported the date of determination the same as the student withdraw date. Effect: The University failed to return Title IV funds to the Department of Education within 45 days of the students’ date of determination as reported on the R2T4 forms. Context: A sample of nine official and unofficial student withdrawals was selected for audit from a population of 63. The test found three student withdrawals that were not in compliance with timely return of funds. Repeat Finding: No. Recommendation: We recommend that the University implement procedures to ensure that R2T4 forms are filed timely and properly reflect the University’s date of determination for all student withdrawals. Management Response: The University concedes that the R2T4 forms improperly reported the date of determination as the same date reported for the student’s date of withdrawal and the University has modified its withdrawal procedures and processes to reflect separate dates when necessary for date of determination and date of withdrawal. Instructions related to R2T4 requirements and timeliness of return of funds will be triggered from the appropriate date of determination. Related to the findings above, the University failed to accurately report the date of determination on R2T4 documentation, causing the return of funds to be out of the window for timely return. Although the funds were returned in a timely manner, the recordkeeping of the determination date was not documented properly. The University has since clarified for staff the importance of this documentation and change in process. Additionally, the university has identified the appropriate test of controls needed to accurately identify the student withdrawal date. This test of controls will be run at the end of each semester, and upon completion, the date the report is run will be used as the correct date of determination. If the Federal Audit Clearinghouse has questions regarding this plan, please call Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer at (540) 887-7285. Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer, Mary Baldwin University, 540-887-7285

View Audit 353780

Finding 555173 (2024-004)

Material Weakness 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director ...

Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limted to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555172 (2024-003)

None 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

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

Identifying Number: 2024-003 Finding: Reporting Context: An incorrect progress report was submitted to the grantor. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-...

Identifying Number: 2024-003 Finding: Reporting Context: An incorrect progress report was submitted to the grantor. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational cjanges such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequesntly. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775

Finding 555171 (2024-002)

Material Weakness 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Identifying Number: 2024-002 Finding: Material Weakness: Allowable Costs/Cost Principles Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were not incurred until 2025. Corrective Actions Taken or Planned: The Director of the Office...

Identifying Number: 2024-002 Finding: Material Weakness: Allowable Costs/Cost Principles Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were not incurred until 2025. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Correcting the gaps between invoicing processes and collecting the Departments/AP proof of payment b. Returning overpayments, if applicable c. Implementing organizational changes such as updated policies and/or procedures d. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices duing the Grant management processes. Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Create processes in which we will adopt verification procedures for invoices and collections. - Create/update Standard Operating Procedures (SOPs) - Provide our team with updated training material (working practice guidelines - WPGs), so they have clear expectations and understand our compliance mechanism. - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555117 (2024-002)

Significant Deficiency 2024

Maine Guaranteed Access Reinsurance Association

ME

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.328

Finding: 2024-002 Federal Agency Name: U.S. Department of Health and Human Services Assistance Listing Number(s): 93.423 Program Name: 1332 State Innovation Waivers Finding Summary: Recipients of federal funds must submit financial reports as required by the Federal award. Reports submitted annually...

Finding: 2024-002 Federal Agency Name: U.S. Department of Health and Human Services Assistance Listing Number(s): 93.423 Program Name: 1332 State Innovation Waivers Finding Summary: Recipients of federal funds must submit financial reports as required by the Federal award. Reports submitted annually by the recipient must be due no later than 90 calendar days after the reporting period. Reports submitted quarterly or semiannually must be due no later than 30 calendar days after the reporting period, in accordance with CFR § 200.328(c). The Association’s existing controls over their reporting processes, to ensure reports were submitted timely, were not functioning in such a way that ensured reports were submitted on time. Responsible Individuals: Christopher E Howard, General Counsel and Secretary Corrective Action Plan: Management has established a multi-tier calendar control to notify them when reports are due in order to ensure timely filing of all reports. Anticipated Completion Date: Completed April 9, 2025.

View Audit 353712

Finding 555112 (2024-002)

Material Weakness 2024

Urban Affairs Coalition

PA

Allowable Costs / Cost Principles Material Weakness Reporting

2024-002 Material Weakness in Internal Control over Compliance 21.023- Emergency Rental Assistance 93.914 – HIV Prevention 93.959 – Block Grants for Prevention and Treatment of Substance Abuse City of Philadelphia, Office of Addition Services (Contract # 22-20537-01) City of Philadelphia, Divi...

2024-002 Material Weakness in Internal Control over Compliance 21.023- Emergency Rental Assistance 93.914 – HIV Prevention 93.959 – Block Grants for Prevention and Treatment of Substance Abuse City of Philadelphia, Office of Addition Services (Contract # 22-20537-01) City of Philadelphia, Division of HIV Health (Contract #21-20003-03 and 22-20537-02) Philadelphia Housing Development Corporation (Contract # 21-20469) Condition: As part of the audit management was to provide us with a complete final trial balance where balances agree to the supporting schedules, reconciliations and documentation provided by management. We noted that the trial balance and general ledger detail reports originally provided by management were (a) delayed, (b) included unreconciled material account balances, (c) multiple journal entries (material and not material), (c) transactions missing from the trial balance, and (d) some reconciliations that either did not agree with the trial balance or individual transactions could not be traced back from the documentation provided to the general ledger. This had caused delays in the completion of the audit, preparation of financial statements, and associated disclosures and the timely arrival of our audit and single audit conclusion. Recommendation: We recommend that management implement policies and procedures as it relates to the reconciliation of accounts, tracking of transactions, and regular review to ensure that calculations of general ledge account balances are accurate and complete. In addition, we continue to recommend that management revisit its financial closing and reporting policies to include updates to its procedures for year-end closes and the timing of when final journal entries and analysis are performed. Repeat Finding: Yes Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Management recognizes the recent delays in timely and accurate financial information and is committed to improving. We will implement updated procedures to ensure the swift and precise presentation of a complete final trial balance that aligns perfectly with the supporting schedules, reconciliations, and documentation. Our enhanced processes will involve promptly recording revenues and expenses, regularly reconciling bank records with accounts, and minimizing journal entries outside the appropriate period. The accounting staff has faced challenges meeting deadlines due to unexpected health issues and recent turnover within the team. Despite these obstacles, we are focused on optimizing our resources and enhancing our efficiency to ensure that tasks are completed on time. Planned completion date for corrective action plan: June 30, 2025

View Audit 353710

Finding 555096 (2024-002)

Material Weakness 2024

Mid-Prairie Community School District

IA

Internal Control / Segregation of Duties Reporting

The District has implemented additional controls such as mandatory vacations for accounting staff and the engagement of an independent accounting professional who performs unannounced reviews of the current activities and processes cited above, as well as reviewing the workflow and work area, includ...

The District has implemented additional controls such as mandatory vacations for accounting staff and the engagement of an independent accounting professional who performs unannounced reviews of the current activities and processes cited above, as well as reviewing the workflow and work area, including electronic and paper files and correspondence of each employee while on their mandatory vacation. Written reports are provided to the Superintendent after each review visit and added to the employee’s personnel file. The District will continue to review internal controls and explore alternatives to improve segregation of duties. It is recognized that due to the size of Central Office staff and budget constraints that many of the segregation of duties issues may continue.

View Audit 353680

Finding 555083 (2024-001)

Significant Deficiency 2024

Jacobs Place Apartments Dba Jacobs Place 074-11032

IA

Subrecipient Monitoring HUD Housing Programs Reporting § 200.512

Finding 2024-001: Statement of condition # 2024-001: For the year ended December 31, 2023, the Corporation did not submit audited financial statements to the Federal Audit Clearinghouse within 30 days after receipt of the auditor's report. The audited financial statements were submitted to the Fede...

Finding 2024-001: Statement of condition # 2024-001: For the year ended December 31, 2023, the Corporation did not submit audited financial statements to the Federal Audit Clearinghouse within 30 days after receipt of the auditor's report. The audited financial statements were submitted to the Federal Audit Clearinghouse on April 12, 2024. Recommendation: The Corporation should submit audited financial statements to the Federal Audit Clearinghouse within the time frames required. Action(s) taken or planned on the finding: The audited financial statements were submitted to the Federal Audit Clearinghouse on April 12, 2024. No further action is required.

View Audit 353624

Finding 555080 (2024-001)

Significant Deficiency 2024

Fair Haven West Apts INC Dba Fair Haven West Apartments 074-Ee044-Wah

IA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.512

Finding 2024-001: Statement of condition # 2024-001: For the year ended December 31, 2023, the Corporation did not submit audited financial statements to the Federal Audit Clearinghouse within 30 days after receipt of the auditor's report. The audited financial statements were submitted to the Fede...

Finding 2024-001: Statement of condition # 2024-001: For the year ended December 31, 2023, the Corporation did not submit audited financial statements to the Federal Audit Clearinghouse within 30 days after receipt of the auditor's report. The audited financial statements were submitted to the Federal Audit Clearinghouse on April 12, 2024. Recommendation: The Corporation should submit audited financial statements to the Federal Audit Clearinghouse within the time frames required. Action(s) taken or planned on the finding: The audited financial statements were submitted to the Federal Audit Clearinghouse on April 12, 2024. No further action is required.

View Audit 353621

Corrective Action Plans

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