Corrective Action Plans

Finding 385038 (2023-001)

Significant Deficiency 2023

Pueblo of Laguna Department of Education

NM

Reporting

2023-001 – Reporting Corrective Action: The Grants Manager has updated our internal worksheet used for preparation of the SF-425 for our BIE programs so that the Repair and Replacement of Indian Schools expenditures are reported. The Grants Manager has also developed a reporting matrix for all of th...

2023-001 – Reporting Corrective Action: The Grants Manager has updated our internal worksheet used for preparation of the SF-425 for our BIE programs so that the Repair and Replacement of Indian Schools expenditures are reported. The Grants Manager has also developed a reporting matrix for all of the Department’s grants, including the semi-annual Head Start grants. Person Responsible: Eric Olson, Controller/Grants Manager Completion Date: June 30, 2024

View Audit 298142

Finding 385035 (2023-002)

Significant Deficiency 2023

Yuba County Water Agency

CA

Reporting § 200.328

Finding 2023-002 — Current Year — Major Federal Award — Significant Deficiency Award No.: 15.507 WaterSMART; Federal Grantor: US Department of the Interior — Bureau of Reclamation, Direct Program Condition: Compliance reporting didn't started until 9+ months after grant agreement was signed due to n...

Finding 2023-002 — Current Year — Major Federal Award — Significant Deficiency Award No.: 15.507 WaterSMART; Federal Grantor: US Department of the Interior — Bureau of Reclamation, Direct Program Condition: Compliance reporting didn't started until 9+ months after grant agreement was signed due to no progress waiting for the Bureau of Reclamation's notice to proceed. This was initially based on grant manager's feedback, who subsequently corrected herself and requested our no activity quarterly reports. Management will adhere to Uniform Guidance even in the event progress reports are to be filed with no activity described. Procedures will require staff to submit the reports, regardless of feedback received from the grant program's manager, to avoid future issues. All performance reports have been filed to date following the Uniform Guidance. All above corrective action items will be implemented by the Finance department at Yuba Water Agency no later than June 30, 2024.

View Audit 298132

Finding 385034 (2023-001)

Significant Deficiency 2023

Yuba County Water Agency

CA

Reporting

Finding 2023-001 — Current Year — Financial Statement Audit — Significant Deficiency Condition: New grant agreement signed near yearend and eligible reimbursements were not booked as revenue. Management will produce procedures to ensure signatories on grants are included in the yearend close process...

Finding 2023-001 — Current Year — Financial Statement Audit — Significant Deficiency Condition: New grant agreement signed near yearend and eligible reimbursements were not booked as revenue. Management will produce procedures to ensure signatories on grants are included in the yearend close process to avoid understating revenue due to unknown activity occurring outside of the finance department. Management agrees grant revenue should be properly reported according to the agreements entered into, as described in GASB No. 33.

View Audit 298132

Finding 385028 (2023-004)

Material Weakness 2023

Newell School District

SD

Reporting Internal Control / Segregation of Duties

FINDING: Audit Adjustments Responsible Individuals: Don Kirkegaard, Interim Superintendent Corrective Action Plan: The District agrees with the above finding and will make the audit adjustments per the auditor’s recommendations. Anticipated Completion Date: Ongoing

View Audit 298115

Finding 385027 (2023-003)

Material Weakness 2023

Newell School District

SD

Reporting

FINDING: Preparation of Financial Statements and Schedule of Expenditures of Federal Awards Responsible Individuals: Don Kirkegaard, Interim Superintendent Corrective Action Plan: The District agrees with the above finding, and the District has accepted the risk associated with the auditor’s prepari...

FINDING: Preparation of Financial Statements and Schedule of Expenditures of Federal Awards Responsible Individuals: Don Kirkegaard, Interim Superintendent Corrective Action Plan: The District agrees with the above finding, and the District has accepted the risk associated with the auditor’s preparing of the financial statements. The District has designated a member of management to review the draft financial statements and accompanying notes to the financial statements. Anticipated Completion Date: Ongoing

View Audit 298115

Finding 385014 (2023-001)

Material Weakness 2023

University of Southern Indiana

IN

Student Financial Aid Special Tests & Provisions Eligibility § 200.303

FINDING 2023-001 Finding Subject: Student Financial Assistance Cluster - Special Tests and Provisions - Enrollment Reporting Summary of Finding: Although the University had policies and procedures in place over Enrollment Reporting, a process to ensure that system defects did not impact reporting re...

FINDING 2023-001 Finding Subject: Student Financial Assistance Cluster - Special Tests and Provisions - Enrollment Reporting Summary of Finding: Although the University had policies and procedures in place over Enrollment Reporting, a process to ensure that system defects did not impact reporting requirements was not implemented. As such, for students who had a reduction or increase in enrollment status during the Spring 2023 term, errors in reporting campus level and program level data went undetected. Students with a status of withdrawn or with no changes during the period were accurately reported. It was recommended that the University's management establish a system of internal controls that includes a review of Banner job processes to verify source data is correctly populated so as to ensure that all data elements required to be submitted to NSLDS are accurate. Contact Person Responsible for Corrective Action: Angel Nelson, Associate Registrar Contact Phone Number and Email Address: (812) 465-1626; angel.nelson@usi.edu Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: While the University of Southern Indiana had internal controls in place to verify the accuracy of our enrollment reporting data, these controls were not effective in discovering system errors. In order to correct this deficiency, the following corrective actions have been implemented: 1. The system defect within our student information system has been corrected by our vendor. 2. All student records affected by the system defect have been corrected in the National Student Loan Clearinghouse database. 3. Beginning in January 2024, the University increased the number of records selected for review from the enrollment file, making sure to review some students who had a reduction or increase in enrollment status, as well as some who had withdrawn. 4. Associate Registrar has subscribed to the e-community for our software vendor to monitor for future system errors. Anticipated Completion Date: The system defect was corrected with the installation of a system patch that was installed on June 4, 2023. All other steps in the corrective action plan have been completed as of January 26, 2024.

View Audit 298073

Finding 385012 (2023-002)

None 2023

Universidad Central De Bayamon INC

PR

Student Financial Aid Special Tests & Provisions Eligibility

Finding No. 2023–002 – Enrollment Reporting Name of Contact Person: Dr. Kendra Ortiz, Registrar Corrective Action Plan UCB recognizes its obligation to report enrollment data to the National Student Loan Data System (NSLDS) at least every 60 days. The Registrar's Office reports enrollment data to NS...

Finding No. 2023–002 – Enrollment Reporting Name of Contact Person: Dr. Kendra Ortiz, Registrar Corrective Action Plan UCB recognizes its obligation to report enrollment data to the National Student Loan Data System (NSLDS) at least every 60 days. The Registrar's Office reports enrollment data to NSLDS on a monthly basis. To ensure that the University comply with the 60-day requirement, we have established an additional notification procedure. The Financial Aid Office will forward report of all Title IV student recipients classified as withdrawn to the Registrar's Office, this process consists of a reconciliation of the data. The Registrar's office will report the enrollment change of this cases to NSLDS within 60 days required. Anticipated completion date: Immediately.

View Audit 298066

Finding 385003 (2023-001)

Significant Deficiency 2023

University of Nebraska

NE

Subrecipient Monitoring Reporting

UNMC Sponsored Programs Accounting will have at least two individuals with access to the FSRS system. A reviewer will sign off on all monthly FFATA reports. This corrective action plan has been implemented effective March 2024. Anticipated Completion Date: March 6, 2024. Contact Name and Telephone...

UNMC Sponsored Programs Accounting will have at least two individuals with access to the FSRS system. A reviewer will sign off on all monthly FFATA reports. This corrective action plan has been implemented effective March 2024. Anticipated Completion Date: March 6, 2024. Contact Name and Telephone Number: Linda Combs, Manager, UNMC Sponsored Programs Accounting, 402-559-5825

View Audit 298065

Finding 384995 (2023-002)

Material Weakness 2023

Lincoln Parish School Board

LA

School Nutrition Programs Subrecipient Monitoring Cash Management

Reference # and title: 2023-002 Internal Control and Compliance over Financial Reporting Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Agriculture; passed through Louisiana Department of ...

Reference # and title: 2023-002 Internal Control and Compliance over Financial Reporting Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Agriculture; passed through Louisiana Department of Education Child Nutrition Cluster: School Breakfast Program AL #10.553 2023 National School Lunch Program AL #10.555 2023 Condition: Louisiana Department of Education (LDOE) requires the School Board to complete monthly claims for reimbursement for meals and snacks served to eligible students within 60 days of the following the last day of the month covered by the claim. Required internal controls over these claims for reimbursement required that all data for the claim be maintained and complete and accurate. Additionally, internal controls require that reports be reviewed by someone other than the person completing the claim. In testing a sample of two months, it was noted that the School Board did not have a review process of the claim by a second person before the claim was submitted. It was also noted that the School Board did not include all students that received meals in requesting for reimbursement as well as the School Board used the wrong CEP percentage in the request for reimbursement. In reviewing the full year’s claims to determine the amount over/under requested, it was noted that these errors caused the School Board to under request for reimbursement in the amount of $20,044. Corrective action planned: The Lincoln Parish School Board hired a new CNP Supervisor in November, 2023 and a new CNP secretary/bookkeeper in December, 2023. CEP reimbursement claim training was conducted on-site with CNP department staff on December 13, 2023, by: - Stephanie Loup – Executive Director of Nutrition – Louisiana Department of Education - Misty Woods – Director of School Food Service– Louisiana Department of Education During this training, the CEP free claim percentage for 2023-2024 was validated as 83.78% and a mock claim worksheet was completed with new administrative staff. This percentage will be validated annually. Regarding the review process of the CEP claim, we have implemented a two-check verification method for this process. Step One is related to the bookkeeper’s responsibilities. The bookkeeper collects and fills out the CNP Reimbursement Claim form in the CNP Claim portal, prints the completed form, and then signs and dates the form before it is submitted to the CNP Supervisor. Step Two is related to the CNP Supervisor’s responsibility. The Supervisor will conduct final review of the report data. If the report is accurate, the Supervisor signs and dates the printed form and returns the form to the Bookkeeper for filing with claim records. Then, the official claim is submitted electronically by the Bookkeeper via the State CNP Claim portal. Person responsible for corrective action: Mr. Cody Carrico, Supervisor of Food Service Phone: (318) 255-1474 Lincoln Parish School Board Fax: (318) 254-1220 1428 Arlington Street Ruston, LA 71270 Anticipated completion date: December 31, 2023 – Actively in place

View Audit 298062

Finding 384989 (2023-001)

Significant Deficiency 2023

Newberry County Memorial Hospital

NC

Questioned Costs Reporting Significant Deficiency

Department of Health and Human Services Newberry County Memorial Hospital respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below....

Department of Health and Human Services Newberry County Memorial Hospital respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The finding from the 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 Department of Health and Human Services 2023-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: We recommend the Organization perform a detailed review of the supporting documentation to ensure accurate expenses are inputted in the internal tracking spreadsheets that is ultimately used by the Management to input into the HRSA reporting portal. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The hospital attempted to track COVID supplies to each nursing unit cost center. This required the Materials Management department to track detailed items in a spreadsheet format. Human error resulted in two of the items being charged with an incorrect amount. The hospital is implementing a new procedure that will improve tracking each expense from the storeroom. An additional step will be for the ACFO to check each month's COVID expense allocation to the spreadsheet to identify potential errors and improve accuracy of the reporting the claimed expenses. Name(s) of the contact person(s) responsible for corrective action: John L. Doyle, Chief Financial Officer Planned completion date for corrective action plan: September 30, 2024 If the Department of Health and Human Services has questions regarding this plan, please call John L. Doyle, CFO, at 803-405-7137

View Audit 298040 Questioned Costs: $1

Finding 384985 (2023-001)

Significant Deficiency 2023

Madison Area Technical College District

WI

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Student Financial Aid Cluster – Assistance Listing No. 84.063 & 84.268 Recommendation: We recommend that the College design and implement controls to ensure reporting to NSLDS are designed to capture all enrolled students and programs offered by the District. Explanation of disagreement with audit...

Student Financial Aid Cluster – Assistance Listing No. 84.063 & 84.268 Recommendation: We recommend that the College design and implement controls to ensure reporting to NSLDS are designed to capture all enrolled students and programs offered by the District. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District worked with NSC to resolve the errors surrounding mismatched CIP codes, resulting in the enrollment report being finalized in late 2022. The College will work with their Records Department to explore accommodations surrounding future term requirements. Name(s) of the contact person(s) responsible for corrective action: Laurie Grigg, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2024

View Audit 298033

Finding 384974 (2023-001)

Significant Deficiency 2023

Community Service Society of New York

NY

Subrecipient Monitoring Reporting Significant Deficiency

Community Service Society (the Society) requires its subrecipients to submit their financial and progress program reports five days after the end of the reporting period. This is done so that the Society can review the underlying documentation in those reports to ensure that proper payments are made...

Community Service Society (the Society) requires its subrecipients to submit their financial and progress program reports five days after the end of the reporting period. This is done so that the Society can review the underlying documentation in those reports to ensure that proper payments are made to the subrecipients and, in turn, proper and timely reports are filed by the Society with the State of New York. There are instances when, because of delays in receipt of information from the subrecipients, or information from the subrecipients needs to be revised, reports are submitted late to the State of New York. The Society notifies the State of New York when reports will be submitted late. In addition, the Society is working with its subrecipients to improve their reporting procedures, as well as the timeliness and accuracy of their reports. This will result in the Society improving the timeliness of its reporting to the State of New York.

View Audit 298015

Finding 384971 (2023-001)

Material Weakness 2023

Oakland Unified School District

CA

HUD Housing Programs Material Weakness Reporting

December 15, 2023 SUBJECT: Corrective Action Plan For Oakland Unified School District for fiscal year ended June 30, 2023- Single Audit Under the provisions of Uniform Administrative Requirement, Cost Principles, and Audit Requirements for Federal Awards at 2 CFR 200 (Uniform Guidance), the auditee ...

December 15, 2023 SUBJECT: Corrective Action Plan For Oakland Unified School District for fiscal year ended June 30, 2023- Single Audit Under the provisions of Uniform Administrative Requirement, Cost Principles, and Audit Requirements for Federal Awards at 2 CFR 200 (Uniform Guidance), the auditee is responsible for follow-up and corrective action plans on all single audit findings. As part of this responsibility, Oakland Unified School District has prepared a corrective action plan for current year audit finding. OUSD’s Expanded Learning Office (ExLO) Conducted a Mandatory Attendance Meeting for all Site Coordinators and Agency Directors. ExLO staff worked alongside 83 different sites to ensure sites were aware of how to accurately track and enter attendance into escape. In addition, ExLO created an attendance dashboard that provides real-time attendance data. This new tool has allowed site coordinators to view attendance data and track missing/incorrect information. Expanded Learning Office has continued to hold regular meetings with Site Coordinators and Agency Directors to review attendance data to ensure high-quality programming occurs at all sites. This includes 4 Agency Directors meeting and 4 All leaders meeting. The Expanded Learning also hired Program Assistants to help support with monthly attendance audits to ensure accurate attendance tracking. This new role also provided on-site support to site coordinators. OUSD has implemented a new Expanded Learning Attendance improved tracking system and provided training to service providers. This new database allows for accurate and prompt attendance taking. 1.OUSD transitioned to a new attendance tracking system. Due to the multiple errors and consistentchanges in attendance, OUSD began using Aeries Supplemental Attendance tracking instead of CitySpanin fall 2021. This transition has allowed the Expanded Learning Office to support struggling sites withreal-time accurate attendance data. 2.On July 29, OUSD held a mandatory Aeries training for all after-school staff and reviewed all CDE (ASES,21st CCLC, and ASSETS) attendance requirements. Over 100 after-school staff attended. 3.All Attendance documents were revised to include Aeries attendance protocols. 4.OUSD Designed dashboards with real-time student and attendance data for all after-school providers. The CDE has accepted the District's CAP as of 8/29/2022.

View Audit 298008

Finding 384964 (2023-005)

Material Weakness 2023

Vienna Public School District #55

IL

Reporting

Name of Contact Person: Greg Frehner, Superintendent. Recommendation: The District should submit the quarterly expenditure reports timely as per the Illinois State Board of Education guidelines. Corrective Action: The District will ensure timely submission during the future and will consider cl...

Name of Contact Person: Greg Frehner, Superintendent. Recommendation: The District should submit the quarterly expenditure reports timely as per the Illinois State Board of Education guidelines. Corrective Action: The District will ensure timely submission during the future and will consider claiming the additional expenditures for the 2024 fiscal year. Proposed Completion Date: Fiscal year 2024.

View Audit 297986

Finding 384944 (2023-003)

Significant Deficiency 2023

Central College

IA

Reporting Student Financial Aid Significant Deficiency

FISAP Reporting Recommendation: We recommend the College evaluate its procedures for reviewing the FISAP and implement changes to validate the information on the FISAP. Views of Responsible Officials and Planned Corrective Actions: This number comes directly from an eligible aid applicant’s report...

FISAP Reporting Recommendation: We recommend the College evaluate its procedures for reviewing the FISAP and implement changes to validate the information on the FISAP. Views of Responsible Officials and Planned Corrective Actions: This number comes directly from an eligible aid applicant’s report. The College has implemented additional oversight procedures for the control to double check figures in future FISAP filings prior to submission. Anticipated Completion Date: September 30, 2023

View Audit 297984

Finding 384943 (2023-002)

Significant Deficiency 2023

Central College

IA

Student Financial Aid Eligibility Reporting

Pell and SEOG Awarding Errors Recommendation: We recommend the College evaluate its procedures for reviewing financial assistance and implement changes to validate the awarding of financial assistance. Views of Responsible Officials and Planned Corrective Actions: When the Department of Education c...

Pell and SEOG Awarding Errors Recommendation: We recommend the College evaluate its procedures for reviewing financial assistance and implement changes to validate the awarding of financial assistance. Views of Responsible Officials and Planned Corrective Actions: When the Department of Education changes Pell Grant eligibility parameters, there is a process that is run to update Pella Grant eligibility in the Datatel processing system. However, when new eligibility parameters increase the number of eligible students due to increasing the estimated family contribution (EFC) eligibility cut-off, there is a separate process that must be run to catch these newly eligible students. This was the scenario in 2022-2023. Six students that were not originally eligible for Pell Grant became eligible. Similar circumstances also occurred in 23-24 and the process was run ensuring all eligible students are being awarded. The additional process has been added to the financial aid calendar to ensure this will not happen in the future. Anticipated Completion Date: September 30, 2023

View Audit 297984

Finding 384942 (2023-001)

Significant Deficiency 2023

Central College

IA

Student Financial Aid Reporting Significant Deficiency

Return of Title IV Funds (R2T4) Calculation Errors Recommendation: We recommend the College evaluate its procedures for reviewing R2T4 calculations and implement changes to validate the inputs to the calculation. Views of Responsible Officials and Planned Corrective Actions: The finding is due to C...

Return of Title IV Funds (R2T4) Calculation Errors Recommendation: We recommend the College evaluate its procedures for reviewing R2T4 calculations and implement changes to validate the inputs to the calculation. Views of Responsible Officials and Planned Corrective Actions: The finding is due to Central College incorrectly inputting the number of break days in the school calendar profile in the R2T4 section of the common origination and disbursement website. When doing annual set-up, the financial aid office will now be confirming correct dates with Central’s controller. The school calendar profiles have already been issued to Forge Financial & Management Consulting for the 23-24 academic year. Anticipated Completion Date: September 30, 2023

View Audit 297984

Finding 384937 (2023-003)

Significant Deficiency 2023

Palmdale Aerospace Academy

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Fiscal year ended June 30, 2023, represents a transition year for the Academy as it is the first fiscal year in which Academy staff has been in charge of processing all accounting and business transactions in‐house. Previously the Academy utilized a back‐office provider. In making the transition to ...

Fiscal year ended June 30, 2023, represents a transition year for the Academy as it is the first fiscal year in which Academy staff has been in charge of processing all accounting and business transactions in‐house. Previously the Academy utilized a back‐office provider. In making the transition to in‐house processing, the Academy has sought to build up the capabilities of its business department, including the full implementation of a new financial software system as well as augmenting the capabilities of staff both in number and in capabilities. In addition, the Academy has made extensive use of expert outside consultants to strengthen its system of internal controls and accounting procedures to ensure that a robust system for processing accounting and business transactions is in place. The Academy will continue to both procure the services of outside experts and augment the capabilities of the business department as deemed necessary. In addition, the departments in charge of maintaining files and records pertinent to financial transactions will strengthen their procedures to ensure that all such files and records are properly maintained, and the business department will audit such on a quarterly basis. The business department will continue to ensure that all accounts receivable, accounts payable, and refundable advances will be reconciled quarterly. As well, at the end of each fiscal year, all areas will be reconciled and adjusted as needed. At the beginning of each fiscal year, all areas will be verified for accuracy and any necessary corrections will be made accordingly.

View Audit 297979

Finding 384932 (2023-002)

Material Weakness 2023

Community Health Project, INC Dba Michael Callen-Audre Lorde Chc

NY

Material Weakness Reporting Internal Control / Segregation of Duties

March 15, 2024 Health Resources and Services Administration Patrick McGovern, Community Health Project, Inc.’s (d/b/a Michael Callen-Audre Lorde Community Health Center’s) CEO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 1301 Avenue of t...

March 15, 2024 Health Resources and Services Administration Patrick McGovern, Community Health Project, Inc.’s (d/b/a Michael Callen-Audre Lorde Community Health Center’s) CEO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS FEDERAL AWARD PROGRAM AUDITS Material Weakness 2023-002 - 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 Organization has implemented policies and procedure to ensure controls are implemented to review against underlying documentation prior to submission to ensure compliance with regulatory agencies. Significant Deficiency 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions Chelsea 356 West 18th Street New York, NY 10011 212.271.7200 Thea Spyer Center 230 West 17th St New York, NY 10011 212.271.7200 Bronx 3144 3rd Ave Bronx, NY 10451 718.215.1800 Recommendation We recommend that management implement their policy that requires board review of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record (EMR) system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Action Taken The organization has implemented an annual approval process for the sliding fee scale to be added as an agenda item for our board approval within the first quarter of every calendar year. For the 2023 sliding fee scale, the board subsequently performed its review and did not find any errors with it thus they retroactively approved and authorized its application We have implemented a procedure whereby the billing department in charge shall seek to obtain this approval annually. Sincerely yours, Signature: Name: Patrick McGovern Title: Chief Executive Officer Organization’s Name: Callen-Lorde Community Health Center Date: 3/15/2024

View Audit 297971

Finding 384924 (2023-034)

Material Weakness 2023

State of Vermont

VT

Subrecipient Monitoring Material Weakness Reporting § 200.303

Public Assistance: Once a subaward has been executed and the cumulative obligated project worksheets have reached the $30,000 reporting threshold, then the Financial Administrator must enter the subaward in FSRS as outlined above. Subsequent project worksheet obligations shall be treated as award am...

Public Assistance: Once a subaward has been executed and the cumulative obligated project worksheets have reached the $30,000 reporting threshold, then the Financial Administrator must enter the subaward in FSRS as outlined above. Subsequent project worksheet obligations shall be treated as award amendments and must be entered into FSRS no later than the last day of the month following the month in which the project worksheet was obligated. Name: Richard Hallenbeck Position: Director of Administration/Finance Email: Richard.hallenbeck@vermont.gov Phone Number: 802 241-5339 Date of Implementation of Corrective Action: 03/31/2024

View Audit 297960

Finding 384922 (2023-033)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements tha...

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements that meet the FFATA reporting requirement have been entered and submitted into the FSRS system by the last business day of each month. Please note that the scheduled completion date is 2/1/23 as the same FFATA reporting finding was identified for a different program during the SFY22 Single Audit, and the corrective action plan was applied across the Department as a whole. The FFATA issues identified in the SFY23 Single Audit pre-dated the implementation of our corrective action plan. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Lillian Smith, VDH Financial Administrator lillian.smith@vermont.gov Jessica Brown, VDH Financial Manager jessica.p.brown@vermont.gov Megan Hoke, VDH Financial Director megan.hoke@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384910 (2023-030)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG...

Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG conducted additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally and reemphasized the FFATA compliance regulations. This ensured the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. The results of the 2023 finding show that the departments understood the training materials and complied with the requirements to report. Although not timely, regarding the reporting in FY2023, the FY2024 should yield timeliness because of the prior year corrective action completion that was closed on 04/11/2023. On at least an annual basis, IAG conducts a review of current federal rules and regulations pertaining to FFATA reporting for FSRS to assure the Agency’s procedures are up to-date. Coincidentally, IAG will also select a random sample of subawards and subawards modifications that meet the required threshold for FFATA reporting to ensure they are reported in FSRS system on a complete, accurate and timely basis. Scheduled Completion Date of Corrective Action Plan: December 31, 2023: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384901 (2023-024)

Material Weakness 2023

State of Vermont

VT

Subrecipient Monitoring Material Weakness Reporting § 200.303

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements tha...

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements that meet the FFATA reporting requirement have been entered and submitted into the FSRS system by the last business day of each month. Please note that the scheduled completion date is 2/1/23 as the same FFATA reporting finding was identified for a different program during the SFY22 Single Audit, and the corrective action plan was applied across the Department as a whole. The FFATA issues identified in the SFY23 Single Audit pre-dated the implementation of our corrective action plan. Scheduled Completion Date of Corrective Action Plan: 2/1/2023 Contacts for Corrective Action Plan: Lillian Smith, VDH Financial Administrator lillian.smith@vermont.gov Jessica Brown, VDH Financial Manager jessica.p.brown@vermont.gov Megan Hoke, VDH Financial Director megan.hoke@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384897 (2023-022)

Significant Deficiency 2023

State of Vermont

VT

Reporting § 200.303

The Department for Children and Families (DCF) recognizes the need to process and file reports timely. In future instances of communication around reports being unavailable and having to file reports off-cycle, the DCF business office will save e-mail communication and ask for transcriptions of meet...

The Department for Children and Families (DCF) recognizes the need to process and file reports timely. In future instances of communication around reports being unavailable and having to file reports off-cycle, the DCF business office will save e-mail communication and ask for transcriptions of meetings. The DCF business office has also established an electronic report-tracking sheet and whiteboard to monitor quarterly reporting status. Scheduled Completion Date of Corrective Action Plan: 10/1/23 Contacts for Corrective Action Plan: Ed Dwinell, DCF Financial Director II ed.dwinell@vermont.gov Shawn Benham, DCF Financial Director III shawn.benham@vermot.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384895 (2023-021)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Due to staff vacancies and turnover that arose in the DCF Quality Assurance & Reporting (QA&R) team during the summer of 2022, there was insufficient intra-team communication and training regarding FFATA reporting requirements. As of January 1, 2024, then, formal procedures and training will be put...

Due to staff vacancies and turnover that arose in the DCF Quality Assurance & Reporting (QA&R) team during the summer of 2022, there was insufficient intra-team communication and training regarding FFATA reporting requirements. As of January 1, 2024, then, formal procedures and training will be put in place to ensure all QA&R staff are prepared to execute their responsibilities pertaining to FFATA reporting requirements. Further, in order to monitor FFATA reporting compliance going forward, AHS Internal Audit Group (IAG) will include LIHEAP subawards in its annual review. Scheduled Completion Date of the Corrective Action Plan: January 1, 2024: FFATA reporting procedures and training in place and operating. December 31, 2024: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Melanie Rutledge, DCF Financial Director I melanie.rutledge@vermont.gov Megan Smeaton, DCF Financial Director IV megan.smeaton@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Corrective Action Plans

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