Corrective Action Plans

Finding 389449 (2023-002)

None 2023

MO

Reporting

Management will review any future reporting requirements and revise future reports as necessary. We have researched the applicable reporting requirements and developed a plan to ensure accurate reports are submitted for any future reporting periods as necessary.

View Audit 300395

Finding 389433 (2023-001)

Material Weakness 2023

Caring Health Center, Inc.

MA

Material Weakness Reporting Internal Control / Segregation of Duties

Health Resources and Services Administration Frank Kostek, Caring Health Center Inc. Vice President and CFO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2023 The finding fro...

Health Resources and Services Administration Frank Kostek, Caring Health Center Inc. Vice President and CFO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS FEDERAL AWARD PROGRAM AUDITS Material Weakness 2023-001 - Accuracy of Reporting to the PRF Portal: U.S Department of Health and Human Services, COVID-19: Provider Relief Fund and American Rescue Plan ("ARP") Rural Distribution: Assistance Listing Number 93.498 - Reporting Recommendation We recommend that the Organization strengthen its system of internal controls to ensure that all reporting that is done and submitted is consistent with requirements and instructions as provided by regulatory agencies. Action Taken The health center reviewed the instructions for filing the Provider Relief Report and we filed the report based on our understanding of the directions. In the future we will review filing directions more carefully and seek guidance from the report source if any reporting requirement is unclear. Sincerely yours, Frank J. Kostek Vice President of Finance, Chief Financial Officer

View Audit 300377

Finding 389391 (2023-001)

None 2023

City of Quincy

MA

Reporting

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The City of Quincy, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannap...

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The City of Quincy, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 Audit period: July 1, 2022, through June 30, 2023 The finding from the June 30, 2023, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. DEPARTMENT OF TREASURY State and Local Fiscal Recovery Fund – Assistance Listing #21.027 2023-001: Reporting of Activities on Treasury Department Project and Expenditure Portal Compliance Requirement: Reporting Criteria or Specific Requirement: For expenditures of program funds received directly from the United States Treasury (Treasury), the City is required to submit quarterly project and expenditure reports to Treasury. Condition: The City is the recipient of program funds directly from Treasury as well as funds passed through Norfolk County. While reconciling total project expenditures reported to Treasury through June 30, 2023, to the City’s ledger, we noted instances where certain invoice expenditures reported to Treasury were also submitted to the County and subsequently reimbursed in fiscal year 2023. Context: The invoices that appear to have been reported to both Treasury and the County represent approximately 3.3% of total expenditures reported to Treasury. Effect: The City has reported expenditures to Treasury that should no longer be classified in this manner. Cause: Management had initially highlighted these invoices as being part of an overall use of program funds received directly from Treasury; however, the fact that the Treasury report needed to be adjusted once the invoices were reclassified to the County funding pool was overlooked. Questioned Costs: None. Recommendation: The City should modify its’ current reconciliation methods between the ledger and program reporting to ensure that instances such as this are identified and corrected promptly. Views of Responsible Officials and Planned Corrective Actions: While completing our typical review of program accounting and reporting, this matter was identified by management during fiscal year 2024. Once this matter was identified, management immediately began working with the Treasury portal to make the appropriate adjustments so that cumulative obligation and expenditure reporting is accurate. If the Oversight Agency has questions regarding this plan, please contact me at 617-376-2706. Sincerely, Eric Mason Chief Financial Officer

View Audit 300374

Finding 389389 (2023-008)

Significant Deficiency 2023

Urshan College

MO

Special Tests & Provisions Subrecipient Monitoring Reporting § 200.303

2023-008 Special Tests and Provisions – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagr...

2023-008 Special Tests and Provisions – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has engaged a firm for GLBA Risk Assessments, has formed a review committee, and prepared a corrective action plan. Name(s) of the contact person(s) responsible for corrective action: Jason Benavides, Interim Director of Financial Aid Planned completion date for corrective action plan: 6/30/2025

View Audit 300370

Finding 389387 (2023-007)

Significant Deficiency 2023

Urshan College

MO

Special Tests & Provisions Student Financial Aid Period of Performance

2023-007 Special Tests and Provisions – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagr...

2023-007 Special Tests and Provisions – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The director of financial aid works with the third-party servicer to ensure accurate student programs and program beginning dates reported to NSLDS. The financial aid office cross references program information within the student information system. Name(s) of the contact person(s) responsible for corrective action: Jason Benavides, Interim Director of Financial Aid Planned completion date for corrective action plan: 6/30/2025

View Audit 300370

Finding 389385 (2023-006)

Significant Deficiency 2023

Urshan College

MO

Matching / Level of Effort / Earmarking Special Tests & Provisions Student Financial Aid § 200.303

2023-006 Special Tests and Provisions – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagr...

2023-006 Special Tests and Provisions – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The director of financial aid works with the third-party servicer to ensure accurate and timely enrollment updates to NSLDS. Name(s) of the contact person(s) responsible for corrective action: Jason Benavides, Interim Director of Financial Aid Planned completion date for corrective action plan: 6/30/2025

View Audit 300370

Finding 389383 (2023-005)

Significant Deficiency 2023

Urshan College

MO

Student Financial Aid Procurement, Suspension & Debarment Internal Control / Segregation of Duties

2023-005 Eligibility – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the a...

2023-005 Eligibility – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The financial aid office designed a new process to coordinate with the academic office to review SAP status of students and ensure appropriate letters will be sent. Name(s) of the contact person(s) responsible for corrective action: Jason Benavides, Interim Director of Financial Aid Planned completion date for corrective action plan: 6/30/2025

View Audit 300370

Finding 389382 (2023-004)

Significant Deficiency 2023

Urshan College

MO

Student Financial Aid Eligibility Reporting

2023-004 Eligibility – Assistance Listing No. 84.063 Recommendation: We recommend the College provide additional resources to ensure all compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findi...

2023-004 Eligibility – Assistance Listing No. 84.063 Recommendation: We recommend the College provide additional resources to ensure all compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The director of financial aid works with the third-party servicer to ensure accurate and timely disbursement dates to COD. Name(s) of the contact person(s) responsible for corrective action: Jason Benavides, Interim Director of Financial Aid Planned completion date for corrective action plan: 6/30/2025.

View Audit 300370

Finding 389378 (2023-006)

Significant Deficiency 2023

South Carolina State University

SC

Student Financial Aid Reporting Internal Control / Segregation of Duties

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in t...

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in the area of internal auditing along with developing a budget line item for this operation. Moving forward, the new internal auditor position will provide needed leadership on all corrective action plans as necessary. The internal auditor will be the point of contact for all audit related matters, thus providing needed onsite management for compliance related issues for the University and its affiliated organizations. In an attempt to seek innovative measures to improve the procedures and internal controls, the Office of Financial Aid has engaged an external consultant to review all critical processes. This will be a fluid engagement, which will aim to self-assess the strength, weaknesses, opportunities, and threats to the efficiency of the department. The University’s failure to reconcile the Fiscal Operations Report and Application to Participate to supporting documentation will be assessed by the new internal audit team. Corrective procedures and additional internal controls to ensure compliance with the special reporting requirements will be developed and/or modified as necessary. In short, the University will enhance our oversight and management of the corrective action plans through the new internal audit team until this matter has been resolved. The University embraces the recommendation to enhance its procedures and internal controls to ensure compliance with the special reporting requirements. Anticipated Completion Date: June 30, 2024

View Audit 300369

Finding 389377 (2023-005)

Significant Deficiency 2023

South Carolina State University

SC

Internal Control / Segregation of Duties Special Tests & Provisions Student Financial Aid

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in t...

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in the area of internal auditing along with developing a budget line item for this operation. Moving forward, the new internal auditor position will provide needed leadership on all corrective action plans as necessary. The internal auditor will be the point of contact for all audit related matters, thus providing needed onsite management for compliance related issues for the University and its affiliated organizations. The University’s inability to provide evidence that a student’s Perkins Loan repayment schedule and another student’s Perkins Loan file were retained as required will be assessed by the new internal audit team. Corrective procedures and additional internal controls to ensure compliance with the special reporting requirements will be developed. In short, the University will enhance our oversight and management of the corrective action plans through the new internal audit team until this matter has been resolved. The University embraces the recommendation to enhance its procedures and internal controls to ensure compliance with the special reporting requirements. Anticipated Completion Date: June 30, 2024

View Audit 300369

Finding 389373 (2023-004)

Significant Deficiency 2023

South Carolina State University

SC

Internal Control / Segregation of Duties Special Tests & Provisions Reporting

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in t...

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in the area of internal auditing along with developing a budget line item for this operation. Moving forward, the new internal auditor position will provide needed leadership on all corrective action plans as necessary. The internal auditor will be the point of contact for all audit related matters, thus providing needed onsite management for compliance related issues for the University and its affiliated organizations. In short, the University will enhance our oversight and management of the corrective action plans through the new internal audit team until this matter has been resolved. The University embraces the recommendation to enhance its procedures and internal controls over the compliance requirements of General Disbursements. The rule requiring the University to wait 30 days before disbursing funds to first time borrowers if the institution does not meet the low default rate requirement must be adhered to and reviewed by the Office of Financial Aid with oversight from the new internal audit team. This will be a critical reporting area for both the Office of Financial Aid and the internal audit team. Anticipated Completion Date: June 30, 2024

View Audit 300369

Finding 389371 (2023-003)

Significant Deficiency 2023

South Carolina State University

SC

Internal Control / Segregation of Duties HUD Housing Programs Reporting

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in t...

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in the area of internal auditing along with developing a budget line item for this operation. Moving forward, the new internal auditor position will provide needed leadership on all corrective action plans as necessary. The internal auditor will be the point of contact for all audit related matters, thus providing needed onsite management for compliance related issues for the University and its affiliated agencies. Management and implementation of current corrective plans are critical to the compliance efforts of the University: To ensure that future reporting of the CARES HEERF funding is posted timely, and in the required format, the University’s Controller, Financial Aid Director and Vice President of Finance and Administration/Chief Finance Officer (CFO) will conduct a monthly review and/or periodically check the Department of Education CARES HEERF FAQs for updates and new requirements. This monthly review process will be overseen by the Assistant Provost for Sponsored Programs, who will function as a neutral third party. In short, the University will enhance our oversight and management of the corrective action plans through the new internal audit team until this matter has been resolved. During the prior reporting periods under review, the University was in the process of submitting and seeking approval of a no-cost extension. During this same period that is under review, the University closed out the current “HEERF” grant and was awarded a “no-cost” extension from the Department of Education. In the University’s attempt to secure a “no-cost” extension from the Department of Education, the reporting schedules under review were developed but not posted to the University’s website as required. The oversight of the reporting process will be a key performance indicator for the internal audit team as we prepare for the “no-cost” extension phase of the grant. Anticipated Completion Date: June 30, 2024

View Audit 300369

Finding 389367 (2023-002)

Significant Deficiency 2023

South Carolina State University

SC

Student Financial Aid Special Tests & Provisions Reporting

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in t...

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in the area of internal auditing along with developing a budget line item for this operation. Moving forward, the new internal auditor position will provide needed leadership on all corrective action plans as necessary. The internal auditor will be the point of contact for all audit related matters, thus providing needed onsite management for compliance related issues for the University and its affiliated organizations. Management and implementation of current corrective plans are critical to the compliance efforts of the University: As stated in the previous corrective action plan the Registrar’s Office in coordination with the Information Technology Division has developed a “flag based” process to capture and monitor enrollment status changes. The implementation and proper reporting of these activities will be led the applicable team with oversight and assistance from the new internal auditing team. As this is a repeated finding, the University‘s corrective action plan will be of the upmost importance to the internal auditing team and all other compliance/operation offices (Registrar’s Office and Academic Affairs Office). The University is requesting a report be filed on the status of this reporting requirement on a semester basis until this matter has been resolved. The new internal audit team will be the lead management unit for this reporting cycle. In short, the University will enhance our oversight and management of the corrective action plans through the new internal audit team until this matter has been resolved. The University embraces the recommendation to enhance its procedures and internal controls over the applicable compliance requirements of enrollment reporting to ensure that all status changes are submitted to NSLDS within the required timeframe. Anticipated Completion Date: June 30, 2024

View Audit 300369

Finding 389363 (2023-001)

Significant Deficiency 2023

South Carolina State University

SC

Student Financial Aid Internal Control / Segregation of Duties Special Tests & Provisions

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in t...

Corrective Action Plan: The University will take immediate action to address the findings of the audit report. As part of the University’s holistic program to improve compliance and assurance, the institution has requested a position number from the State of South Carolina Human Resource office in the area of internal auditing along with developing a budget line item for this operation. Moving forward, the new internal auditor position will provide needed leadership on all corrective action plans as necessary. The internal auditor will be the point of contact for all audit related matters, thus providing needed onsite management for compliance related issues for the University and its affiliated agencies. In an attempt to seek innovative measures to improve the procedures and internal controls, the Office of Financial Aid has engaged an external consultant to review all critical processes. This will be a fluid engagement, which will aim to self-assess the strength, weaknesses, opportunities, and threats to the efficiency of the department. Management and implementation of current corrective plans are critical to the compliance efforts of the University: The University has made the necessary changes to the staff and will continue to assess the efficiency of the review process to include, but not limited to, the hiring of both a Senior Financial Aid Counselor and a Director of Transfer Students. The new Director of Transfer Students will have the necessary access/ability to generate the information and update the system to improve the University’s capability to monitor requirements of Title IV aid to ensure enhanced compliance. This will eliminate the challenge created by multiple financial aid counselors being assigned the responsibility for initiating the process, generating the information, and updating the system on a weekly basis. In addition, the Director of Financial Aid will receive alerts when the process has been completed, and perform periodic reviews, using sample populations, to ensure the process is being done timely and accurately. As this is a repeated finding, the University ‘s corrective action plan will be of the upmost importance to the internal auditing team and all other compliance offices (Director of Financial Aid and Director of Transfer Students). The University is requesting a report be filed on the status of our transfer students on a semester basis until this matter has been resolved. The new internal audit team will be the lead management unit for this reporting cycle. In short, the University will enhance its oversight and management of the corrective action plans through the new internal audit unit until this matter has been resolved. Anticipated Completion Date: June 30, 2024

View Audit 300369

Finding 389359 (2023-001)

Significant Deficiency 2023

Molloy College

NY

Student Financial Aid Special Tests & Provisions Reporting

Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Finding 2023-001 – Special Tests and Provisions – Enrollment Reporting Name of contact person responsible for corrective action: Linda Albanese, Vice President Enrollment Management; lalbanese@molloy.edu; 516-323-4025 Molloy University u...

Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Finding 2023-001 – Special Tests and Provisions – Enrollment Reporting Name of contact person responsible for corrective action: Linda Albanese, Vice President Enrollment Management; lalbanese@molloy.edu; 516-323-4025 Molloy University understands the finding and has devised a process to ensure students who submit a request to withdraw which is effective after the completion of the current semester get processed manually in NSLDS once the semester has ended. To aid in this updated practice, a documented procedure has been established that provides a checklist of steps and collection of internal signatures to be completed for each student who indicates they wish to withdraw from the University. Additionally, we will be engaging a consultant to perform a compliance review with the US Department of Education for Enrollment Reporting. This will ensure that the withdrawal status is promptly provided within the required timeframe. Proposed completion date: February 20, 2024

View Audit 300357

Finding 389356 (2023-002)

Significant Deficiency 2023

Antioch University

OH

Special Tests & Provisions Student Financial Aid Period of Performance

Corrective Action Taken or Planned: The University has experienced changes in staffing for personnel involved in enrollment reporting and system irregularities with multiple programs with the National Clearing House. These inconsistencies have caused delays in processing and response to enrollment r...

Corrective Action Taken or Planned: The University has experienced changes in staffing for personnel involved in enrollment reporting and system irregularities with multiple programs with the National Clearing House. These inconsistencies have caused delays in processing and response to enrollment reporting changes. Antioch University has hired a new Director of Records Administration with a primary responsibility for NSLDS reporting. The University will implement a comprehensive training plan for new individuals and teams, including improved documentation of procedures, increased clarity regarding the process for the necessity of error resolution, and a review of system processing to help reduce errors in reporting and increase efficiency. In addition, internal reviews and control audits will be performed throughout the year to ensure accuracy in NSLDS reporting and alignment with the National Clearing House guidance. Person Responsible for Corrective Action: Maureen Heacock, the Registrar and Katy Stahl, Executive Director of Financial Aid & Scholarships are responsible for executing the corrective action plan. Anticipated Completion Date: Fiscal year 2024

View Audit 300356

Finding 389355 (2023-001)

Significant Deficiency 2023

Antioch University

OH

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Corrective Action Taken or Planned: Starting with the 2024-2025 Award year, the Office of Financial Aid and Scholarships is undergoing an internal reorganization. The purpose of this is to provide a broader depth of knowledge and better dual control and compliance functions within the Office of Fina...

Corrective Action Taken or Planned: Starting with the 2024-2025 Award year, the Office of Financial Aid and Scholarships is undergoing an internal reorganization. The purpose of this is to provide a broader depth of knowledge and better dual control and compliance functions within the Office of Financial Aid and Scholarships. In the new reorganization structure, the FA Specialist will be responsible for performing the R2T4 Calculations, with their Supervisor, the Assistant Director of Financial Aid Operations, reviewing and approving the calculation. Once the calculation is completed, and signed off on by the Assistant Director, the FA Specialist will will complete and send the Financial Aid Transmittal Register (FATR) report and notify the Student Accounts Office so they can process the return of funds on through the Financial Aid Posting Register (FATP). Review of the Financial Aid Posting Register will be done by the FA Specialist to ensure the internal process to return funds is timely and posted to the Common Origination and Disbursement system accurately. A quarterly review and internal control audit of Title IV refund calculations will also be completed to ensure accuracy in system processing, days and break calculations, and adherence to Title IV regulations. In addition, the staff will have additional training throughout the year on Title IV compliance and refunds to ensure the University is compliant with all regulations. Person Responsible for Corrective Action: Katy Stahl, the Executive Director of Financial Aid & Scholarships, is responsible for the execution of the corrective action plan. Anticipated Completion Date: Fiscal year 2024

View Audit 300356

Finding 389354 (2023-002)

Significant Deficiency 2023

Economic Development and Industrial Corporation of Boston

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303

EDIC will update its current internal controls for submitting subaward information to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) and will create a new submission into FSRS each month to report any required subaward information in accordance with the prog...

EDIC will update its current internal controls for submitting subaward information to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) and will create a new submission into FSRS each month to report any required subaward information in accordance with the program requirements.

View Audit 300355

Finding 389345 (2023-003)

Significant Deficiency 2023

Hht Foundation International, INC

MD

Questioned Costs Reporting § 200.303

The outsourced accounting firm will create and execute a year-end process that will analyze all payments made during the 60 days following the fiscal year-end to ensure that expenses are recorded in the correct fiscal year. This process will ensure the Schedule of Expenditures of Federal Awards (SEF...

The outsourced accounting firm will create and execute a year-end process that will analyze all payments made during the 60 days following the fiscal year-end to ensure that expenses are recorded in the correct fiscal year. This process will ensure the Schedule of Expenditures of Federal Awards (SEFA) is reported properly. The grant program manager will ask vendors to submit their invoices for services rendered through the fiscal year end to Cure HHT within 30 days of the fiscal year end. Each grant contract year differs from the Cure HHT fiscal year. Cure HHT will create and execute a grant reconciliation process that involves financial reporting from the outsourced accounting firm, members of the outsourced accounting team, Cure HHT grant managers, and Cure HHT management to validate that all cost reimbursable grants recognize revenue as costs are incurred. All parties will ensure appropriate accounting processes and controls are in place on an ongoing basis. The reconciliation process will take place monthly and at fiscal year-end.

View Audit 300345 Questioned Costs: $1

Finding 389344 (2023-002)

Significant Deficiency 2023

Hht Foundation International, INC

MD

Questioned Costs Cash Management Reporting § 200.303 § 200.305

This error occurred during a time of transition from one outsourced accounting firm and accounting system to another. The new outsourced accounting systems were not fully in place or automated at the time of the reporting error and there was no internal review process. The outsourced accounting firm...

This error occurred during a time of transition from one outsourced accounting firm and accounting system to another. The new outsourced accounting systems were not fully in place or automated at the time of the reporting error and there was no internal review process. The outsourced accounting firm is now fully transitioned, all systems are fully integrated with the accounting software, and the accounting team provides the program managers and organization managers with the reports needed to prepare drawdown requests. Cure HHT has developed and fully implemented a corrective action plan. The organization has communicated with the cognizant agency and all expenses eligible for submission for payment through grant funding will be submitted to and paid from the overdrawn funds. Once these funds are depleted, the organization will resume monthly draw submissions for all eligible expenses. The organization will reconcile all eligible expenses prior to requesting grant funds to avoid future duplicate and/or incorrect requests for grant funds. In addition, pending proper internal approvals of all submitted expenses, grant funds received will be dispersed within 3-7 business days from the date received.

View Audit 300345 Questioned Costs: $1

Finding 389343 (2023-004)

Material Weakness 2023

New Castle County, Delaware

DE

Subrecipient Monitoring Material Weakness Reporting § 200.303

MATERIAL WEAKNESS 2023-004 Community Development Block Grant/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County subsequently report the subawards not reported in FSRS. We further recommend the County strengthen controls and procedures to ensure that all r...

MATERIAL WEAKNESS 2023-004 Community Development Block Grant/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County subsequently report the subawards not reported in FSRS. We further recommend the County strengthen controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Community Services was made aware of the FFATA issue at the end of FY22. The Department developed and executed a Standard Operating Procedure (SOP) to ensure all awards over $30,000 were submitted to the FSRS system within the required time. In FY23 we entered the FY22 and FY23 sub-recipient awards in FSRS. In FY23 there were expenses for sub-recipient awards that were issued in FY20 and FY21, which was identified by CLA. The Department will modify our SOP to require all sub-recipient awards be entered regardless of the fiscal year they were awarded; this ensures accurate and up-to-date reporting. Name(s) of the contact person(s) responsible for corrective action: Mike Kapa Planned completion date for corrective action plan: June 30, 2024

View Audit 300342

Finding 389334 (2023-001)

Significant Deficiency 2023

Lake County Crisis Center D/b/a A Safe Place

IL

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Finding 2023-001 – Significant Deficiency: Reporting - Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: Completed September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure t...

Finding 2023-001 – Significant Deficiency: Reporting - Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: Completed September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission. Update: A Safe Place developed an infrastructure and implemented internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission. The Program Administrative Manager will ensure all program performance reports (PPR) will be reviewed and submitted timely.

View Audit 300326

Finding 389332 (2023-002)

Material Weakness 2023

The Thresholds and Affiliated Organizations

IL

Reporting Material Weakness

Condition: An award passed through IDHS was not initially classified with the correct assistance listing number on the Schedule of Expenditures of Federal Awards (SEFA) by the Agency. The incorrect ALN was identified during audit procedures and corrected by the Agency. Planned Corrective Action: Thr...

Condition: An award passed through IDHS was not initially classified with the correct assistance listing number on the Schedule of Expenditures of Federal Awards (SEFA) by the Agency. The incorrect ALN was identified during audit procedures and corrected by the Agency. Planned Corrective Action: Thresholds will have a colleague outside of the Grants team (Controller or SVP for Finance) review future SEFAs. We will pay particular attention to ensure all expenditures are shown with the correct ALN, dollar amounts, and other fields. Contact person responsible for corrective action: Al Shoreibah, Chief Financial Officer Anticipated Completion Date: April 1, 2024

View Audit 300324

Finding 389331 (2023-001)

Material Weakness 2023

The Thresholds and Affiliated Organizations

IL

Material Weakness Reporting

Condition: The Organization's controls in place for reporting submissions did not identify Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to the lost revenue calculations. The Period 4 reporting submission for...

Condition: The Organization's controls in place for reporting submissions did not identify Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to the lost revenue calculations. The Period 4 reporting submission for lost revenue did not follow the acceptable options outlined by HHS. Additionally, the Period 2 reporting submission, completed in the previous year, did not follow the acceptable options. Planned Corrective Action: Thresholds will have a second individual (Controller or SVP for Finance) review future award applications that are one-time or unusual in nature. We will pay particular attention to review the terms carefully so that Thresholds does not misunderstand things (such as the acceptable options, as in this case). Contact person responsible for corrective action: Al Shoreibah, Chief Financial Officer Anticipated Completion Date: April 1, 2024.

View Audit 300324

Finding 389330 (2023-001)

Material Weakness 2023

Trihealth

OH

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

Federal Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF), Assistance Listing No. 93.498 Federal Agency: U.S. Department of Health and Human Services (HHS) Planned Responsible Officials: Mike Crofton, VP of Finance and Interim Chief Financial Officer C...

Federal Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF), Assistance Listing No. 93.498 Federal Agency: U.S. Department of Health and Human Services (HHS) Planned Responsible Officials: Mike Crofton, VP of Finance and Interim Chief Financial Officer Corrective Action: TriHealth is committed to ensuring internal controls are implemented to ensure compliance with Section 200.303 of the Uniform Guidance. In response to the findings, TriHealth has or will implement the following policies and procedures: 1. Design and implement controls over our any future PRF reporting, including both General Distributions and Targeted or Rural Distributions, to ensure the necessary documentation is submitted in the HHS Reporting Portal and that the information submitted is complete and accurate based on accounting records and other data. This will include retention of necessary documentation to support reported expenditures and lost revenues and that such documentation is reviewed by TriHealth’s Controller and VP of Finance and Interim Chief Financial Officer. 2. Utilize Internal Audit to perform detail review and testing over the PRF program reporting, as applicable. This will include the use of Internal Audit to review PRF reporting prior to submission to the HHS Portal, as well as appropriateness of lost revenue and allowability of healthcare related expenses. 3. Prior to submission, the Controller and the Executive Director of Internal Audit will review the draft reporting submissions with the Executive Director of Decision Support and Reimbursement prior to submitting the reports in the HHS Portal. As TriHealth and its affiliates did not receive PRF General Distributions in excess of $10,000, individually or in the aggregate, during PRF Reporting Period 6 (payments received from July 1, 2022 to December 31, 2022), TriHealth will not be required to submit any future reporting in the HHS Portal for PRF General Distributions. However, TriHealth will ensure appropriate levels of review occur for any future reporting of PRF or similar federal funding, including PRF Targeted or Rural Distributions.

View Audit 300321

Corrective Action Plans

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