Corrective Action Plans

Finding 540662 (2024-018)

Material Weakness 2024

NH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 93.268 Immunization Cooperative Agreements and 93.268 COVID-19 Immunization Cooperative Agreements State Agency: Department of Health and Human Services (DHHS) Audit Contact: Hannah Glines and Melissa Kelleher Title: Revenue Director an...

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 93.268 Immunization Cooperative Agreements and 93.268 COVID-19 Immunization Cooperative Agreements State Agency: Department of Health and Human Services (DHHS) Audit Contact: Hannah Glines and Melissa Kelleher Title: Revenue Director and Grants Administrator of Bureau of Contracts and Procurement Telephone: 603-271-9043 and 603-271-9637 E-mail address: Hannah.J.Glines@dhhs.nh.gov and Melissa.J.Kelleher@dhhs.nh.gov Audit Report Reference: 2024-018 – Reporting - FFATA Anticipated Completion Date: September 30, 2025 Corrective Action Planned: FFATA procedures will be reviewed and strengthened to ensure adequate controls are in place. This will include training other members of the federal reporting staff so that there is sufficient separation of duties for preparation, review, approval, and timely submittal of the reports. The contracts were all in process prior to the April 4, 2022, inception of the UEI, and had been prepared with the DUNS number. However, the appropriate UEI was obtained to perform the required FFATA reporting requirements using SAM.GOV.

View Audit 350389

Finding 540647 (2024-015)

Material Weakness 2024

State of New Hampshire

NH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 93.044, 93.045, 93.053 Aging Cluster State Agency: Department of Health and Human Services (DHHS) Audit Contact: Hannah Glines and Melissa Kelleher Title: Revenue Director and Grants Administrator of Bureau of Contracts and Procurement T...

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 93.044, 93.045, 93.053 Aging Cluster State Agency: Department of Health and Human Services (DHHS) Audit Contact: Hannah Glines and Melissa Kelleher Title: Revenue Director and Grants Administrator of Bureau of Contracts and Procurement Telephone: 603-271-5052 and 603-271-9637 E-mail address: Hannah.J.Glines@dhhs.nh.gov, Melissa.J.Kelleher@dhhs.nh.gov Audit Report Reference: 2024-015 – FFATA Reporting Anticipated Completion Date: September 30, 2025 Corrective Action Planned: FFATA procedures will be reviewed and strengthened to ensure adequate controls are in place. This will include training other members of the federal reporting staff so that there is sufficient separation of duties for preparation, review, approval, and timely submittal of the reports. The contracts were all in process prior to the April 4, 2022, inception of the UEI, and had been prepared with the DUNS number. However, the appropriate UEI was obtained to perform the required FFATA reporting requirements using SAM.GOV.

View Audit 350389

Finding 540642 (2024-014)

Material Weakness 2024

State of New Hampshire

NH

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 84.425 COVID-19 Education Stabilization Fund State Agency: Education Department (ED) Audit Contact: Lindsey Labonville Title: Administrator IV Telephone: 603.731.4621 E-mail address: Lindsey.L.Labonville@doe.nh.gov Audit Report Referenc...

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 84.425 COVID-19 Education Stabilization Fund State Agency: Education Department (ED) Audit Contact: Lindsey Labonville Title: Administrator IV Telephone: 603.731.4621 E-mail address: Lindsey.L.Labonville@doe.nh.gov Audit Report Reference: 2024-014, 2023-008; 2022-013, 2022-016; 2021-013, 2021-015 - Reporting Anticipated Completion Date: 06/30/2025 Corrective Action Planned: The NHED concurs with this finding. We acknowledge these discrepancies with a note regarding section b and c. These discrepancies are associated with ESSER III and not ESSER II. The lack of documentation is due to employee turnover. Locating documentation was a challenge for the ESSER Reporting. We are currently reviewing the FY24 reports and making corrections. The corrected ESSER Recipient Data Collection Form will be updated and refiled during the Year 4 re-open period on 7/28/2025. Documentation will be centrally located in the common drive clearly marked. The review process will be well documented with completed sign-off documentation to confirm reconciliation between the GMS system and NH First, the financial system of record.

View Audit 350389

Finding 540637 (2024-013)

Material Weakness 2024

State of New Hampshire

NH

Reporting Subrecipient Monitoring Material Weakness § 200.303

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 84.425 COVID-19 Education Stabilization Fund - FFATA State Agency: Education Department (ED) Audit Contact: Lindsey Labonville Title: Administrator IV Telephone: 603.731.4621 E-mail address: Lindsey.L.Labonville@doe.nh.gov Audit Report ...

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 84.425 COVID-19 Education Stabilization Fund - FFATA State Agency: Education Department (ED) Audit Contact: Lindsey Labonville Title: Administrator IV Telephone: 603.731.4621 E-mail address: Lindsey.L.Labonville@doe.nh.gov Audit Report Reference: 2024-013; 2023-008; 2022-013, 2022-016; 2021-013, 2021-015 - FFATA Reporting Anticipated Completion Date: 06/30/2025 Corrective Action Planned: The NHED concurs with this finding. The FFATA reporting procedure was redefined last year with updates to the GMS system implemented. GMS was updated to issue the GAN upon initial allocation instead of upon first approval of activities in the system. There were a few grants where the initial allocation was uploaded into GMS in 2021 with the first approval of activities completed after the GMS update. The GAN for these few grants was not created due to the change in procedure. Through the reconciliation process, these issues were identified and GANs were created later than anticipated. Moving forward, this will not be an issue as this was a limited transition period.

View Audit 350389

Finding 540636 (2024-012)

Material Weakness 2024

State of New Hampshire

NH

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Material Weakness § 200.303

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 21.029 Coronavirus Capital Project Funds State Agency: Department of Business and Economic Affairs (BEA) Audit Contact: Kathy Fredericksen Title: Administrator III Telephone: (603) 271-0260 E-mail address: Kathleen.C.Fredericksen@livef...

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 21.029 Coronavirus Capital Project Funds State Agency: Department of Business and Economic Affairs (BEA) Audit Contact: Kathy Fredericksen Title: Administrator III Telephone: (603) 271-0260 E-mail address: Kathleen.C.Fredericksen@livefree.nh.gov Audit Report Reference: 2024-012 and 2023-006 - Reporting Anticipated Completion Date: No Later than 6/30/2025 Corrective Action Planned: In response to a similar finding in the 2023 audit, the Department modified reporting procedures to strengthen the precision of the reconciliation of reporting data to the Capital Project Fund dashboard. These changes were made prior to the end of the audit period but after the September 30th reporting cycle. Accordingly, the Department would note the application of audit procedures to the June 30, 2024, report did not identify similar errors. Regarding the tracking and reporting of actual total miles of fiber deployed and actual total locations; the Department would note Federal guidance documents state actual miles are not required to be reported until a project is completed. The “Coronavirus Capital Projects Fund: States, Territories, and Freely Associated States Project and Expenditure Report User Guide” (updated 12/20/2024) specifically instructs recipients to “Input the total miles of fiber planned to be deployed by the project” and “Provide the number of locations the project plans expect to serve”. Both of these instructions are accompanied by a notation stating actual amounts should be reported for projects marked as complete. The Department will take measures to ensure, upon project completion, reporting elements will be updated to reflect actual miles of fiber and locations served as per guidance. In doing so, and recognizing the unique characteristics of these reporting elements, the Department will take measures to obtain support sufficient to ensure the reported data elements are accurate. The Department is also taking measures during the active project period to review progress and expenditure allowability at project milestones, ensuring sufficient support and project progress.

View Audit 350389

Finding 540631 (2024-009)

Material Weakness 2024

State of New Hampshire

NH

Subrecipient Monitoring Material Weakness Reporting § 200.303

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 WIOA Cluster (Assistance Listing #17.258, #17.259, #17.278) State Agency: Department of Business and Economic Affairs Audit Contact: Kathy Fredericksen Title: Administrator III Telephone: (603) 271-0260 E-mail address: Kathleen.C.Frederi...

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 WIOA Cluster (Assistance Listing #17.258, #17.259, #17.278) State Agency: Department of Business and Economic Affairs Audit Contact: Kathy Fredericksen Title: Administrator III Telephone: (603) 271-0260 E-mail address: Kathleen.C.Fredericksen@livefree.nh.gov Audit Report Reference: 2024-009 - Reporting Anticipated Completion Date: No Later than 6/30/2025 Condition: Federal Financial Accountability and Transparency Act (FFATA) reports during the fiscal year ending June 30, 2024, were not filed in compliance with the Transparency Act related to WIOA programs. View of Responsible Officials: BEA concurs with the audit finding and has an anticipated completion date to the corrective action plan of June 30, 2025. Corrective Action Planned: BEA will evaluate polices & procedures as well as existing internal controls in place to ensure that the precision level of the control is such that it would detect an error in the reporting requirements in comparison to reports required to be filed versus filed and that all documentation used to support the data reported on the federal report(s) are properly maintained. Furthermore, BEA will enhance policies and procedures and re-implement to include internal controls ensuring all FFATA reports are submitted in compliance with the Transparency Act reporting requirements. BEA will ensure staff attends appropriate compliance trainings.

View Audit 350389

Finding 540620 (2024-006)

Material Weakness 2024

State of New Hampshire

NH

Reporting § 200.303 § 200.502 § 200.510

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 Fish and Wildlife Cluster (Assistance Listing #15.605, #15.611, #15.626) State Agency: NH Fish and Game Department Audit Contact: Kathy LaBonte Title: Business Division Chief Telephone: 603 271-2274 E-mail address: kathy.a.labonte@wildli...

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 Fish and Wildlife Cluster (Assistance Listing #15.605, #15.611, #15.626) State Agency: NH Fish and Game Department Audit Contact: Kathy LaBonte Title: Business Division Chief Telephone: 603 271-2274 E-mail address: kathy.a.labonte@wildlife.nh.gov Audit Report Reference: 2024-006 – SEFA Reporting Anticipated Completion Date: Completed Corrective Action Planned: Improved internal controls to evaluate amounts reported on the SEFA have been implemented. We concur in part with the finding: A. Out-of-period expenditure amounts were incorrectly included on the SEFA. These amounts have been identified and corrections have been made. B. Same as above. C. The Department partially concurs. For one grant, W108-L2 / F21AF04030, the amount understated is actually $5,431. As previously explained, a portion of the amount listed as understated, was a Donation to the purchase of property, and not a direct Department Expenditure. ($112.500.00). Corrections have been made to the SEFA. D. Only the total Federal share of expenditures were reported on the SEFA. The Department does perform reconciliations and pre-audits of information entered into QuickBooks to verify data is complete and accurate. Improved internal controls to evaluate the amounts reported on the SEFA have been implemented.

View Audit 350389

Finding 540617 (2024-003)

Material Weakness 2024

State of New Hampshire

NH

Internal Control / Segregation of Duties Cash Management Material Weakness § 200.303

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 12.401 National Guard Military Operations and Maintenance (O&M) Projects State Agency: Department of Military Affairs and Veterans Services (DMAVS) Audit Contact: Judy Chen Title: Administrator Telephone: 603-225-1366 E-mail address: yin...

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 12.401 National Guard Military Operations and Maintenance (O&M) Projects State Agency: Department of Military Affairs and Veterans Services (DMAVS) Audit Contact: Judy Chen Title: Administrator Telephone: 603-225-1366 E-mail address: ying.q.chen@DMAVS.nh.gov Audit Report Reference: 2024-003, 2023-002 – Reporting Anticipated Completion Date: None Corrective Action Planned: Non Concur This requires the Department to create a redundant manual ledger that duplicates the function of the current ledger and DTR. This is not an efficient use of time or personnel. DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all transactions that reconciles every month to NH First Detail Transaction Register (DTR), Federal Fund tracking sheet, and Federal reimbursement tracking sheet with backup documents. The tracking sheet for the federal register is not intended to account for the state share of billing. The state share is accurately accounted for in the DTR, the cumulative accounting in the SF-270 and associated back up documentation. Supporting documentation to substantiate the accuracy of lines a, c, e, and f is in the DTR, the cumulative accounting of each SF-270, the supporting documentation sent with the billing to the Federal Government, and Year-end Agency Report for Federal Awards. This includes reconciliation and analysis of SADB expenditures and revenues to the Statement of Appropriations by each Program Accounting Unit. The SF-270 form is continuous cumulative data that starts Oct 1st and runs through the end of that Federal Fiscal Year. The SF-270 is the required federal form DMAVS submits to the Federal National Guard Appendix Program Manager for reimbursement. Back up documentation is submitted with the SF-270. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense to affect the cash draw. DMAVS does not unilaterally make cash draws to the federal government. The USPFO, who is substantially involved provides an independent review and reconciles any discrepancies prior to approving any requests for reimbursement. One possible explanation for the finding is that the selected test works were not continuous, nor did they account for cumulative data.

View Audit 350389

Finding 540613 (2024-002)

Material Weakness 2024

State of New Hampshire

NH

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.1 § 200.303

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 10.553/10.555/10.556/10.559 Child Nutrition Cluster State Agency: Education Department Audit Contact: Lindsey Labonville Title: Administrator IV Telephone: 603.731.4621 E-mail address: Lindsey.L.Labonville@doe.nh.gov Audit Report Refer...

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 10.553/10.555/10.556/10.559 Child Nutrition Cluster State Agency: Education Department Audit Contact: Lindsey Labonville Title: Administrator IV Telephone: 603.731.4621 E-mail address: Lindsey.L.Labonville@doe.nh.gov Audit Report Reference: 2024-002 - Child Nutrition Cluster Finding Anticipated Completion Date: June 30, 2025 Corrective Action Planned: The NHED concurs with this finding. NHED contacted the US Department of Agriculture (USDA) for information on FFATA reporting requirements for state education agencies. The contact at USDA, Suzanne Dagesse, responded on February 6, 2024, that they were not aware of the requirement, and that this requirement has never been communicated to the NHED Office of Food & Nutrition Programs, by USDA. NHED has had annual reviews conducted by USDA of the programs administered and this requirement has never been communicated. NHED will add the food and nutrition programs to the established FFATA process already implemented to ensure that amounts to subrecipients are tracked and that all first tier subawards of $30,000 or more are reported in accordance with FFATA.

View Audit 350389

Finding 540612 (2024-003)

Material Weakness 2024

The Crenulated Company Ltd.

NY

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Reporting § 200.306 § 200.403 § 200.434

The Crenulated will request a quarterly in-kind contribution report from DOE and will ensure the in-kind contributions are recorded in the financial statements. The Crenulated plans to hire an in-house Controller with expertise in accounting for grants, and review its existing contract with current ...

The Crenulated will request a quarterly in-kind contribution report from DOE and will ensure the in-kind contributions are recorded in the financial statements. The Crenulated plans to hire an in-house Controller with expertise in accounting for grants, and review its existing contract with current third-party accounting provider.

View Audit 350384

Finding 540606 (2024-003)

Significant Deficiency 2024

Spencer Mountain Road Volunteer Fire Department

NC

Reporting Matching / Level of Effort / Earmarking

The Organization will also look into hiring an independent accountant to assist with financial statement preparations to ensure accuracy. The Organization will also take steps to ensure the loan liability balance held at South State Bank is reported accurately.

View Audit 350381

Finding 540605 (2024-002)

Material Weakness 2024

Spencer Mountain Road Volunteer Fire Department

NC

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

The Organization’s Board of Directors will ensure its review of the monthly bank statements, reconciliations and cancelled check images, payroll registers, financial statements and general ledger activity is documented through physical signatures, sign off with initials or email approval. The Organi...

The Organization’s Board of Directors will ensure its review of the monthly bank statements, reconciliations and cancelled check images, payroll registers, financial statements and general ledger activity is documented through physical signatures, sign off with initials or email approval. The Organization will also look into hiring an independent accountant to assist with financial statement preparations.

View Audit 350381

Finding 540601 (2024-001)

Significant Deficiency 2024

Syracuse University

NY

Student Financial Aid Reporting Matching / Level of Effort / Earmarking § 200.303

Corrective Action Plan Year-end June 30, 2024 The following finding was noted during the audit of Federal programs in accordance with 2 CFR 200. Management of Syracuse University agrees with the finding and proposes the following Corrective Action Plan. Finding Number 2024-001: Enrollment Reporting ...

Corrective Action Plan Year-end June 30, 2024 The following finding was noted during the audit of Federal programs in accordance with 2 CFR 200. Management of Syracuse University agrees with the finding and proposes the following Corrective Action Plan. Finding Number 2024-001: Enrollment Reporting Corrective Action Plan: The University has identified a remediation plan in response to the finding, including the following: 1. Immediate Mitigations (within 90 Days): a. The Office of the Registrar and Office of Financial Aid and Scholarship programs will formalize a quarterly check-in meeting with multiple levels of stakeholders to ensure that our enrollment reporting process is complying and to address any new concerns that may arise. These check-in meetings have been scheduled and begin on March 26, 2025. 2. Long-Term Mitigations (within 12 months) a. The Office of the Registrar will work with Information Technology Services colleagues to implement a Graduates Only Enrollment file for multi-career students to increase the quantity of records that can be automatically processed. This work will be made productional by February 1, 2026 i. This will reduce our error rate and decrease the volume of records requiring manual review, allowing for more focused attention on the most complicated scenarios. Responsible individuals: Michele B Sipley, Executive Director of Financial Aid Kelly Campbell, University Registrar

View Audit 350372

Finding 540598 (2024-001)

Significant Deficiency 2024

The Trustees of Davidson College

NC

Student Financial Aid Matching / Level of Effort / Earmarking Reporting § 200.303

The correc􀆟ve ac􀆟on plan is as follows: Anna L. Stovall, with the assistance of the Registrar’s office, will review the status of graduated students during the first two weeks in June 2025, to ensure their effec􀆟ve graduate date is accurately reported. Further, those students who have informed David...

The correc􀆟ve ac􀆟on plan is as follows: Anna L. Stovall, with the assistance of the Registrar’s office, will review the status of graduated students during the first two weeks in June 2025, to ensure their effec􀆟ve graduate date is accurately reported. Further, those students who have informed Davidson College that they are on a leave of absence will also be reviewed in the coming weeks. It is an􀆟cipated that these ac􀆟vi􀆟es will be completed not later than June 30, 2025. These ac􀆟ons are in response to audit finding 2024-001.

View Audit 350366

Finding 540593 (2024-001)

Significant Deficiency 2024

Southern Oregon University

OR

Student Financial Aid Subrecipient Monitoring Reporting § 200.303

Recommendation: We recommend that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: Ther...

Recommendation: We recommend that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Student Records Specialist and University Registrar will be reviewing and revising policies and procedures related to enrollment reporting with the Clearinghouse data which then feeds into NSLDS. SOU will review calendar preparations, data collection, data submission and confirmation, error handling, file preparation documentation/instructions to identify breakdown in the process that lead to noncompliant reporting. SOU will increase monitoring of Clearinghouse data and also reach out to Clearinghouse to identify reports/tools that can assist with accurate and timely reporting. Name(s) of the contact person(s) responsible for corrective action: Rose Reinhart, Interim Registrar Planned completion date for corrective action plan: June 2025

View Audit 350358

Finding 540591 (2024-004)

Significant Deficiency 2024

Municipality of Vega Baja

PR

Subrecipient Monitoring Cash Management Reporting

COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF VEGA BAJA Corrective Action Plan For the Fiscal Year Ended June 30, 2024 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit P...

COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF VEGA BAJA Corrective Action Plan For the Fiscal Year Ended June 30, 2024 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2023 – June 30, 2024 Fiscal Year: 2023-2024 Principal Executive: Hon. Marcos Cruz Molina, Mayor Contact Person: Mr. Edgardo Pérez, Department of Management, Administration and Budget Director Phone: (787)855-2500 Original Finding Number: 2024-004 Statement of Concurrence or Non concurrence: We concur with the finding. Corrective Action: The ACUDEN agency has not yet closed the budget year 2023-2024. Therefore, even though the contract has ended, the remaining reimbursement from the agency has not been received. Therefore, the full closing report cannot be completed until this final amount is received. As a corrective measure for finding 2024-005, the Sub Director of Finance will establish an internal control system in which the processes and compliance with the submission of accounting reports for federal programs, including Child Care, will be periodically monitored. Implementation Date: Fiscal Year 2025-2026. Responsible Person: José A. Mathews Maisonet Program Accountant

View Audit 350357

Finding 540590 (2024-003)

Significant Deficiency 2024

Municipality of Vega Baja

PR

Subrecipient Monitoring Reporting Significant Deficiency § 200.302 § 200.328 § 200.329

COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF VEGA BAJA Corrective Action Plan For the Fiscal Year Ended June 30, 2024 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit P...

COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF VEGA BAJA Corrective Action Plan For the Fiscal Year Ended June 30, 2024 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2023 – June 30, 2024 Fiscal Year: 2023-2024 Principal Executive: Hon. Marcos Cruz Molina, Mayor Contact Person: Mr. Edgardo Pérez, Department of Management, Administration and Budget Director Phone: (787)855-2500 Original Finding Number: 2024-003 Statement of Concurrence or Non concurrence: We concur with the finding. Corrective Action: In the quarterly reports (QPR), accumulated expenses are reported up to the closing date of each quarter. These expenses are assigned to the quarter in which the contractor invoices the completed work. However, in some cases, the payment is made in the quarter following the one in which the invoice was issued. This discrepancy may cause the expenses not to be accurately reflected in the quarter they were reported during the audit process. This situation will be addressed prospectively, and expenses will be assigned to the quarter in which the payment is made. Implementation Date: Fiscal Year 2025-2026. Responsible Person: José A. Torres Otero Program Accountant

View Audit 350357

Finding 540583 (2024-004)

Material Weakness 2024

Triad Adult and Pediatric Medicine, INC

NC

Reporting

For the 2023 Uniform Data System (UDS) report, the data was compiled using information from two different Electronic Medical Record (EMR) systems. Due to this system fragmentation, there were reporting shortfalls, and the organization relied on historical data estimates to ensure timely submission o...

For the 2023 Uniform Data System (UDS) report, the data was compiled using information from two different Electronic Medical Record (EMR) systems. Due to this system fragmentation, there were reporting shortfalls, and the organization relied on historical data estimates to ensure timely submission of the report. These estimates were used to comply with the UDS submission requirements, despite the data not being fully supported by direct system generated reports. For the 2024 UDS report, the organization transitioned to a single EMR system, which has significantly improved the accuracy and completeness of the data. All reported amounts for the 2024 UDS submission are now fully supported by backup data directly generated from the unified EMR system. It is important to note that the Health Resources and Services Administration (HRSA) has consistently approved the organization’s Federal Financial Report (FFR) submissions without including program income, and as such, the organization was not aware of a potential noncompliance issue related to this omission. Going forward, the organization’s Uniform Data System (UDS) reports will be consistent and based on data extracted from a single, unified Electronic Medical Record (EMR) system. This transition ensures greater accuracy and completeness in reporting, with all future UDS reports supported by direct system-generated data. Additionally, the organization will begin reporting program income on the Federal Financial Report (FFR) as part of ongoing improvements to ensure full compliance with reporting requirements. It is important to note that the current FFR report was approved by the Health Resources and Services Administration (HRSA) without program income listed, and this omission was not previously identified as a noncompliance issue. The organization is committed to maintaining transparent and accurate reporting in the future, and steps are being taken to ensure that all required data, including program income, is properly reflected in all relevant reports. This is the responsibility of the QI department and the CFO and will be complete following the next filing of the FFR and UDS.

View Audit 350343

Finding 540573 (2024-002)

Material Weakness 2024

Whittier College

CA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding 2024-002 Enrollment Reporting: The Office of the Registrar acknowledges the finding related to delayed status reporting and agrees that there were instances where student information was not transmitted within the required timeframe. Although a process is now in place to support more consi...

Finding 2024-002 Enrollment Reporting: The Office of the Registrar acknowledges the finding related to delayed status reporting and agrees that there were instances where student information was not transmitted within the required timeframe. Although a process is now in place to support more consistent and timely submissions, earlier delays were influenced by staffing changes and operational challenges. To ensure ongoing compliance, the Office of the Registrar has implemented an updated submission schedule that aligns with federal reporting expectations. Enrollment and graduation data are now submitted regularly and any reporting errors are corrected and resubmitted within the 10-day recommended timeframe. These steps are part of our ongoing efforts to maintain data accuracy and comply with institutional and regulatory standards. Implementation Date: August 2025 Person Responsible: Brianna Mendez, Student Data Specialist, Office of the Registrar

View Audit 350321

Finding 540572 (2024-001)

Material Weakness 2024

Whittier College

CA

Reporting Student Financial Aid

inding 2024-001 – Reporting: The Financial Aid office concurs with the audit of Pell 15-day reporting finding. The compliance is clearly stated the timeframe to send an original Pell Grant disbursement to COD is within 15 days of the date of disbursement. We also understand we have the permission,...

inding 2024-001 – Reporting: The Financial Aid office concurs with the audit of Pell 15-day reporting finding. The compliance is clearly stated the timeframe to send an original Pell Grant disbursement to COD is within 15 days of the date of disbursement. We also understand we have the permission, as stated per Federal Regulations, to go back into the account and make an adjustment as needed. This allows us to change the disbursement to make a correction. We have worked with our software vender Ellucian Banner to create a process that will solve this issue to ensure Pell Grants are originated on COD thus allowing the disbursements to be sent within the 15-day compliance timeframe. We will continue to monitor the Pell Grants to ensure any issues get resolved, if any noted, in a timely manner. Implementation Date: August 2025 Person Responsible: Jesse Marquez Associate Director and Information Specialist of Financial Aid Julie Aldama Financial Aid Director

View Audit 350321

Finding 540554 (2024-001)

None 2024

Universidad Central Del Caribe, Inc.

PR

Student Financial Aid Eligibility Reporting

1. Implement new communication channels to align process to NSLDS and the USDoE.  Engage with NSLDS: Requested an access token for the data manager to monitor and reconcile data submitted.  Reach out to NSLDS to coordinate new reconciliation reports out of NSLDS database. 2. Training  Maintain su...

1. Implement new communication channels to align process to NSLDS and the USDoE.  Engage with NSLDS: Requested an access token for the data manager to monitor and reconcile data submitted.  Reach out to NSLDS to coordinate new reconciliation reports out of NSLDS database. 2. Training  Maintain sustained training and preparation for the staff. 3. Implement a weekly review process to doublecheck the entries for changes in enrollment reporting in NSLDS.  Implement a Document Changes and Actions Log: Keep detailed records of all changes made to procedures and actions taken to address the audit findings. This documentation can be useful for future reviews.  The Registrar will assure that all changes (LOA, withdrawals, re entries, and reclassifications, completions, graduations) are entered weekly and documented across all databases (NSLDS, Jenzabar student record, SRS, others as applicable).

View Audit 350312

Finding 540549 (2024-006)

Significant Deficiency 2024

Independent School District #2909, Rock Ridge Public Schools

MN

Internal Control / Segregation of Duties Cash Management Reporting

Contact Person – Dr. Noel Schmidt, Superintendent Corrective Action Plan – The District staff will establish procedures to review meal reimbursement submissions. Completion Date – Immediately

View Audit 350310

Finding 540547 (2024-101)

Significant Deficiency 2024

County of Yavapai

AZ

Reporting § 200.508 § 200.510

Community Health Services will add a historical tracking mechanism for multi-year grants so that Assistance Lising numbers are tracked each year with explanations for changes. The tracking mechanism will be updated with contracts, contract amendments and purchase order releases. The tracking mechani...

Community Health Services will add a historical tracking mechanism for multi-year grants so that Assistance Lising numbers are tracked each year with explanations for changes. The tracking mechanism will be updated with contracts, contract amendments and purchase order releases. The tracking mechanism will feed into the annual Schedule of Expenditures of Federal Awards preparation spreadsheet that is provided to Yavapai County Finance.

View Audit 350301

Finding 540539 (2024-001)

Significant Deficiency 2024

Puerto Rico Housing Finance Authority

PR

Subrecipient Monitoring Reporting

We are implementing a review system with clear lines of responsibility and standardized checklists to ensure comprehensive and timely report submissions. Concurrently, the CDBG-DR Area personnel responsible of filing the monthly progress reports will participate regularly in the trainings provided b...

We are implementing a review system with clear lines of responsibility and standardized checklists to ensure comprehensive and timely report submissions. Concurrently, the CDBG-DR Area personnel responsible of filing the monthly progress reports will participate regularly in the trainings provided by the PRDOH’s Subrecipient Management Area regarding the Grant Compliance Portal, including trainings about the reporting requirements, data management, and deadline adherence. It is crucial to note that the submission of the monthly progress report is contingent upon the approval of the previous month's progress report by the Puerto Rico Department of Housing (PRDOH), our grantor, consistent with the guidelines outlined in the GCP Manual. To minimize the return of progress reports for corrections and standardize the required information and narratives, we have established recurring meetings with PRDOH to discuss requested revisions and ensure timely approval of monthly reports, thereby guaranteeing PRHFA's ability to submit reports on time. Detailed documentation will be maintained for all processes, training, and reviews, ensuring continuous improvement and compliance with reporting standards.

View Audit 350286

Finding 540536 (2024-006)

Significant Deficiency 2024

New Mexico Department of Homeland Security & Emergency Management

NM

Reporting Subrecipient Monitoring Cash Management § 200.302 § 200.303

Recommendation We recommend the Department review the instructions for completion of the federal financial reports with training provided to the program staff preparing and reviewing the federal financial reports to ensure submitted reports are complete. We recommend the Department implement effecti...

Recommendation We recommend the Department review the instructions for completion of the federal financial reports with training provided to the program staff preparing and reviewing the federal financial reports to ensure submitted reports are complete. We recommend the Department implement effective processes and procedures to maintain the submitted reports and the documentation used to prepare the reports in the files of the Department. Management Response Corrective Action: The Department understands the issues and is continuing to take corrective action to improve reporting. In the past the Department has shifted its priority to onboarding across the Department, and we have onboarded a Grants Unit Manager to oversee the reporting requirements of all federal grants. The Grants Unit will focus on procedures to ensure the reporting requirements are met. A procedural checklist will be implemented to ensure that: 1. the recipient share section is completed, 2. that financial reports are submitted to the Department timely, and 3. all Performance Progress Reports as submitted. Due Date of Completion: June 30, 2025 Responsible Person(s): Deputy Cabinet Secretary, Grants Unit Manager

View Audit 350283

Corrective Action Plans

Filters