Corrective Action Plans

Finding 555193 (2024-001)

Material Weakness 2024

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

Finding 555075 (2024-001)

None 2024

Silver Lake Housing, Inc.

TX

Cash Management HUD Housing Programs Reporting

Audit Finding 2024-001: Condition: The tenant security deposit cash account was insufficient to cover the tenant security deposit liability. - Response: The reserve for replacement has ample funds to request reimbursements of qualified expenditures for the last two years to catch up on outstanding...

Audit Finding 2024-001: Condition: The tenant security deposit cash account was insufficient to cover the tenant security deposit liability. - Response: The reserve for replacement has ample funds to request reimbursements of qualified expenditures for the last two years to catch up on outstanding payables and fund the deficiency in the security deposit account. Management is going to request a Budget Based Rent increase for the property since the OCAF increases for the last few years to not keep up with the extraordinary escalation of operating costs of the last three years. Management believes that with these steps it will be able to return to its previous cash flow position. - Name and Title of contact person responsible for corrective action: - Linda Holder, Executive Director – Houston Housing Management Corporation - PO Box 1819 - Houston, TX 77002 - 713-526-9470

View Audit 353614

Finding 555074 (2024-002)

Significant Deficiency 2024

San Diego Association of Governments

CA

Reporting Period of Performance

We concur with the auditor's recommendation to enhance internal controls, ensuring compliance with timely reporting as required by the grant agreements. Calendar reminders will be added to staff's calendars, and multiple levels will be notified of the reporting submissions.

View Audit 353604

Finding 554988 (2024-001)

Significant Deficiency 2024

The Center for Victims of Torture

MN

Subrecipient Monitoring Eligibility Reporting

Views of Responsible Officials: CVT will add to a comprehensive sub-recipient checklist timely FFATA reporting and review training with Finance staff working with sub-recipient.

View Audit 353602

Finding 554985 (2024-001)

Significant Deficiency 2024

New Mexico Veterans Integration Centers

NM

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.403 § 200.414

View of Responsible Officials and Corrective Action Plan We acknowledge the findings and appreciate the diligence of the audit team in identifying the discrepancies in our indirect cost calculations and reporting as outlined in the draft findings. The Veterans Integration Center (VIC) is committed t...

View of Responsible Officials and Corrective Action Plan We acknowledge the findings and appreciate the diligence of the audit team in identifying the discrepancies in our indirect cost calculations and reporting as outlined in the draft findings. The Veterans Integration Center (VIC) is committed to maintaining the highest standards of compliance with all federal regulations and grant requirements. Corrective Action Plan 1. Training and Guidelines: All relevant staff will undergo training to understand and implement the correct procedures for calculating indirect costs. Comprehensive guidelines will be developed and disseminated to ensure consistency across all calculations and reporting. 2. Completion of SF-425 Jointly: The COO, and VIC’s contracted Accountant will confirm the accurate Modified Total Direct Costs (MTDC) which is to be used in completing the SF-425, then prepare the GPD SF-425 jointly to ensure its accuracy. 3. Review and Approval Process: An additional layer of review and approval will be established for all indirect cost calculations before they are reported. This step will involve our Chief Executive Officer (CEO) to ensure accuracy and compliance. Corrective Action Plan Timeline • Staff Training and Guidelines Distribution: Completed by Q4 2025 • Completion of SF-425 Jointly: Starting Q3 2025 with SF-425 revision • Review and Approval Process: Effective immediately, with CEO, reviews starting Q3 2025 Designation of Employee Position Responsible for Meeting Deadline The Chief Operating Officer (COO) will be responsible for the oversight and successful implementation of the corrective action plan. The COO will coordinate with the contracted internal Accountant to ensure all actions are taken within the stipulated timelines and report directly to the Chief Executive Officer on the progress.

View Audit 353588 Questioned Costs: $1

Finding 554962 (2024-005)

Significant Deficiency 2024

Thomas More University

KY

Reporting Student Financial Aid Significant Deficiency

Finding 2024-005 Enrollment Reporting: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans, Pell Grants AL #: 84.268, 84.063 Award Year: 2023-2024 Condition: Nine out of eighteen Enrollment Reporting rosters received were returned back after 15 days...

Finding 2024-005 Enrollment Reporting: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans, Pell Grants AL #: 84.268, 84.063 Award Year: 2023-2024 Condition: Nine out of eighteen Enrollment Reporting rosters received were returned back after 15 days. Corrective Action Planned: The late Enrollment Reporting was a result of the significant turnover in the Registrar's office. The University formed an oversight committee outside of the Registrar's office that corrected inaccurate reporting and worked through the backlog to meet reporting requirements. The experienced oversight committee will train the Registrar's office in continuing this timely compliance process for Enrollment Reporting and can backstop if any future personnel turnover or other event could negatively impact timely reporting. Responsible Party: Mark Messingschlager, Director of Financial Aid Anticipated Completion Date: Immediately

View Audit 353567

Finding 554956 (2024-002)

Material Weakness 2024

Iliff School of Theology

CO

Student Financial Aid Reporting Material Weakness

Condition: Our audit procedures identified instances of untimely reporting of enrollment information to NSLDS. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The School has also ensur...

Condition: Our audit procedures identified instances of untimely reporting of enrollment information to NSLDS. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The School has also ensured that this third-party processor is properly coordinated with the registrar’s office to meet federal requirements for NSLDS enrollment reporting. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: June 2024

View Audit 353566

Finding 554954 (2024-003)

Significant Deficiency 2024

City of Fosston

MN

Reporting

Contact Person – Cassandra Heide, City Administrator Corrective Action Plan – Will establish a procedure to ensure all reporting is filed timely. Completion Date – Immediately

View Audit 353561

Finding 554952 (2024-004)

None 2024

Ascentria Community Services, Inc.

MA

Reporting Internal Control / Segregation of Duties

U.S. Department of Health and Human Services Refugee and Entrant Assistance Discretionary Grants – Assistance Listing No. 93.576 Recommendation: The Organization should review internal controls to ensure required filings are submitted timely and evidence of submission are retained as documentation...

U.S. Department of Health and Human Services Refugee and Entrant Assistance Discretionary Grants – Assistance Listing No. 93.576 Recommendation: The Organization should review internal controls to ensure required filings are submitted timely and evidence of submission are retained as documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing is current standard operating procedures to ensure that timely submissions occur, and evidence of submissions is retained in a central repository. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris Planned completion date for corrective action plan: June 30, 2025 and Ongoing

View Audit 353549

Finding 554949 (2024-003)

None 2024

Ascentria Community Services, Inc.

MA

Reporting Internal Control / Segregation of Duties

U.S. Department of Health and Human Services Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should review internal controls to ensure required filings are submitted timely. Explanation of disagreement...

U.S. Department of Health and Human Services Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should review internal controls to ensure required filings are submitted timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing is current standard operating procedures to ensure that timely submissions occur, and evidence of submissions is retained in a central repository. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris Planned completion date for corrective action plan: June 30, 2025 and Ongoing

View Audit 353549

Finding 554940 (2024-001)

Significant Deficiency 2024

Community Health & Wellness Partners of Logan County

OH

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Data compiled to prepare a report is saved with a final copy of the report to support the information...

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Data compiled to prepare a report is saved with a final copy of the report to support the information is complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CHWP has made enhancements to its financial reporting structure and used this in calculating the UOS data for CY 2024. We believe that we documented the numbers appropriately but will make sure that we continue to comply with this requirement in future UOS reporting, Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025.

View Audit 353547

Finding 554905 (2024-001)

Significant Deficiency 2024

Western Suffolk Boces

NY

Procurement, Suspension & Debarment Special Tests & Provisions Equipment & Real Property Management

U.S. Department of Education Year ended June 30, 2024 Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing #84.063) Federal Direct Student Loans (Assistance Listing #84.268) Compliance Requirement: Special Tests and Provisions Criteria: The Gramm-Leach-Bliley Act (Pub...

U.S. Department of Education Year ended June 30, 2024 Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing #84.063) Federal Direct Student Loans (Assistance Listing #84.268) Compliance Requirement: Special Tests and Provisions Criteria: The Gramm-Leach-Bliley Act (Public Law 106-102) (GLBA) requires the BOCES, on an annual basis, to identify reasonably foreseeable internal and external risks to the security, confidentiality, and integrity of customer (student) information that could result in the unauthorized disclosure, misuse, alteration, destruction, or other compromise of such information, and assess the sufficiency of any safeguards in place to control these risks. At a minimum, the GLBA risk assessment should include consideration of risk in each relevant area of operations, including: 􀀄 Employee training and management. 􀀄 Information systems, including network and software design, as well as information processing, storage, transmission, and disposal. 􀀄 Detecting, preventing, and responding to attacks, intrusions, or other system failures. Condition: During our testing, we noted the following: 􀀄 A periodic inventory of data, noting where it is collected, stored, and transmitted was not performed. 􀀄 Vulnerability scanning and penetration testing is not completed annually. 􀀄 A written information security program is not fully in place. Policies surrounding risk management have not been implemented. 􀀄 Unsupported operating systems in use. Cause: The expected documentation supporting the required controls to adequately confirm compliance with GLBA safeguards was not complete. Effect: Without demonstrable, documented controls supporting compliance with the GLBA standards for safeguarding the protected data, compliance with the law and the requirements in the federal PPA may not be assured. Context: Inquiry and observation of the information received from the BOCES related to compliance with GLBA. Auditor’s Recommendation: The BOCES should review the GLBA safeguarding rules and as soon as practical implement and document the controls necessary for compliance with the rule, focusing on the completion of a documented, thorough, and standardized risk assessment and management reporting framework. The BOCES should perform comprehensive risk assessments on a regular basis, which is suggested to be at least annually, and at any significant change in infrastructure or business process. Contact Period Responsible for Corrective Action Plan: Warren Taylor, Chief Financial Officer Corrective Action Plan and Timing of Planned Corrective Action Plan: The BOCES is actively engaged in a formal Request for Proposals (RFP) process to procure a qualified vendor for the design and implementation of a comprehensive Information Security Program aligned with GLBA requirements. The selected vendor will conduct a full assessment of existing controls, help develop required policies and procedures, and assist in ensuring full compliance with GLBA mandates, including employee training, information systems safeguards, and incident response protocols. This process will be completed by December 2025. As part of the upcoming vendor engagement, a complete data inventory and structured risk assessment will be conducted. This will identify where sensitive data is collected, stored, transmitted, and processed, and will form the basis for implementing technical and administrative safeguards. This process will be completed by March 2026. In the past several years the BOCES has reviewed several student systems and was unable to identify a system that met all of their needs due to the differences between requirements applicable to school districts and those appropriate to the unique needs of a BOCES. The organization is on track to discontinue the use of all unsupported operating systems by June 30, 2026.

View Audit 353484

Finding 554903 (2024-001)

None 2024

United Cerebral Palsy Housing Development Fund Corporation, Inc.

NY

Reporting HUD Housing Programs

Finding Number: 2024-001 Reporting – Noncompliance (Control Deficiency) Programs: U.S. Department of Housing and Urban Development - Project Based Rental Assistance (PBRA) (Section 8 Project-Based Cluster), Award Listing Number 14.195. Planned Corrective Action: The Corporation acknowledges that the...

Finding Number: 2024-001 Reporting – Noncompliance (Control Deficiency) Programs: U.S. Department of Housing and Urban Development - Project Based Rental Assistance (PBRA) (Section 8 Project-Based Cluster), Award Listing Number 14.195. Planned Corrective Action: The Corporation acknowledges that the 2024 data collection form and REAC filing were not filed timely. The planned correction plan is to file the 2024 data collection form and REAC filing upon the issuance of the Uniform Guidance financial statements and ensure that future data collection forms and REAC filing are submitted timely. Person Responsible: A’isha Torrence, Chief Financial Officer Expected Completion Date: June 2025

View Audit 353466

Finding 554902 (2024-001)

Significant Deficiency 2024

Cares of Ny, Inc.

NY

Reporting § 200.303 § 200.502 § 200.510

CORRECTIVE ACTION PLAN 3/27/2025 US Department of Health and Human Services CARES of NY, Inc. respectfully submits the following corrective action plan for the year ended April 30, 2024. Name and address of independent public accounting firm: Wojeski & Company CPAs, PC 159 Wolf Road Albany, NY 1...

CORRECTIVE ACTION PLAN 3/27/2025 US Department of Health and Human Services CARES of NY, Inc. respectfully submits the following corrective action plan for the year ended April 30, 2024. Name and address of independent public accounting firm: Wojeski & Company CPAs, PC 159 Wolf Road Albany, NY 12205 Audit period: Year ending April 30, 2024 The findings from the April 30, 2024 schedule of findings and questions costs are discussed below. The findings are numbered consistent with the numbers assigned in the schedule. Finding 2024-0001 – Reporting of the Schedule of Expenditure of Federal Awards Recommendation: We recommend that the Organization implement additional processes and procedures to ensure that the SEFA is complete and accurate. Corrective Action plan taken: The corrective action taken was to notify Auditors as soon as the error was realized so that audits could be corrected. There is no need for further corrective action. This incident was isolated and not recurring. The grant for which this finding is associated was a temporary covid grant that has since ended. To prevent future errors for occurring, all new contracts will be reviewed prior to submitting the summary of federal awards to the auditor to ensure that any federally sourced funding is properly identified regardless of grantor. CARES of NY, Inc. will implement a check and balance procedure where the grants director will review the listing prior to audit submission for accuracy. Responsible Person for corrective action plan: Eileen Wiebicke, Chief Financial Officer Anticipated completion date for corrective action plan: 1/24/2025 (date auditors were notified of error) If the US Department of Health and Human Services has questions regarding this plan, please call Eileen Wiebicke at 518-489-4130 x 702.

View Audit 353463

Finding 554890 (2024-001)

Significant Deficiency 2024

Asian and Pacific Islander Wellness Center, Inc. D/b/a San Francisco Community Health Center

CA

Reporting Subrecipient Monitoring Significant Deficiency

2024‐001 Compliance Over Reporting Asian and Pacific Islander Wellness Center Inc. dba San Francisco Community Health Center [SFCHC] accepts this finding. A new CFO is hired in November 2024 with over 30 years of high‐level nonprofit experience in reporting compliance and finance and business operat...

2024‐001 Compliance Over Reporting Asian and Pacific Islander Wellness Center Inc. dba San Francisco Community Health Center [SFCHC] accepts this finding. A new CFO is hired in November 2024 with over 30 years of high‐level nonprofit experience in reporting compliance and finance and business operations. The new CFO has over 10 years as CFO/COO for two federally qualified health centers and immediately reviewed existing policies and procedures with focus on federal grants and compliance reporting. The next single audit submission for fiscal year ended March 31, 2025, will be submitted to the Federal Audit Clearinghouse [FAC] without delay. We are now planning timeline to commence independent review starting mid‐July. The estimated field audit will be completed by October 15. We are anticipating submission to FAC and other regulatory agencies no later than December 15, 2025, within 9 months from fiscal year [March 31]. At SFCHC, we re‐enforced the centralization of documents and records and secured sensitive information, reviewing access and rights of users to avoid compromising data. We also enabled the ‘attachment’ feature at MIP Fund Accounting. Accounting transactions along with documentation lived in digital files. A compliance calendar is now disseminated quarterly and shared with programs. We will be posting the same to SFCHC intra‐net and will be renewed each quarter. Anticipated Completion Date: At this time, the condition noted by our auditor is now addressed and will be tracked for progress. We are hiring additional staff to support grants and contracts administration, monitoring and reporting compliance. Responsible party: Rosalia Aquino Chief Financial & Compliance Officer April 9, 2025

View Audit 353455

Corrective Action Plans

Filters