Corrective Action Plans

Finding 390192 (2023-001)

None 2023

NY

Allowable Costs / Cost Principles Reporting

Finding 2023-001: (A) (B) Unallowed COVID-19 expenditures reported within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of...

Finding 2023-001: (A) (B) Unallowed COVID-19 expenditures reported within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of Health and Human Services (HHS) Award Year: 1/1/2020-6/30/2023 Award Number: Not available Management’s Response to Finding: Management acknowledges that certain COVID-19 expenditures were overstated in the Period 4 Reporting period HRSA portal submissions by the University of Rochester and Related Entities (“the University”). Management’s Corrective Action Plan: As provided in HRSA’s FAQs regarding Auditing and Reporting Requirements for Provider Relief Fund Payments, a provider is allowed to replace its unallowable expenses with its unreimbursed lost revenues in the reporting period in question if a provider is not required to report in subsequent reporting periods. None of the related entities with findings have future required HRSA portal submission. Both UR Medicine Home Care and Nicholas H. Noyes Memorial Hospital had unreimbursed lost revenue that exceeded the identified unallowable expenses in Reporting Period 4. In accordance with HRSA’s guidance, UR Medicine Home Care and Nicholas H. Noyes Memorial Hospital will replace the unallowable expenses with unreimbursed lost revenue. St. James Hospital did not report enough unreimbursed lost revenue to replace the unallowable expenses. However, St. James Hospital has identified additional allowable expenses and a miscalculated lost revenue amount for Reporting Period 4 that would exceed the identified unallowable expenses. Further, enterprise-wide, the University had unreimbursed lost revenue that far exceeded the identified unallowable expenses. As the University is unable to amend Reporting Period 4 for St. James Hospital, the University will document the additional allowable expenses and miscalculated lost revenue amount in case of future inquiries. The URMC Office of the Chief Financial Officer, in support with the Office of University Audit, the Controller’s Office, and the University of Rochester Medical Center (URMC) Office of Integrity and Compliance, distributed enterprise-wide guidelines in FY23 to assist each entity with respect to allowable COVID-19 expenditures to help ensure reporting was complete and accurate. The University also conducted enterprise-wide reviews of the HRSA Reporting portal submissions of all University affiliates prior to submission to the HRSA. The University will continue to conduct enhanced reviews with respect to its future required portal submissions.

View Audit 301098

Finding 390182 (2023-001)

Material Weakness 2023

Ascension Parish School Board

LA

Reporting § 200.502 § 200.510

The Business Service Department will work with CSRS to ensure the FEMA funded projectes are reported correctly on the SEFA. Timeline: Immediately Responsible Person: Naquisha Larks, Grants Accountant

View Audit 301090

Finding 390170 (2023-001)

Significant Deficiency 2023

Prince William Sound Science and Technology Institute

AK

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Lack of Internal Control over Reporting and Noncompliance Name of Contact: W. Scott Pegau Corrective Action Plan: A new section on contracts was added to our accounting manual that describes the steps to be taken when a new contract is established. It identifies the need for the FFATA reporting....

Lack of Internal Control over Reporting and Noncompliance Name of Contact: W. Scott Pegau Corrective Action Plan: A new section on contracts was added to our accounting manual that describes the steps to be taken when a new contract is established. It identifies the need for the FFATA reporting. A second procedure outlines how to complete the required reporting. All existing subcontracts over $30,000 were reported as required. Proposed completion date: December 15, 2023.

View Audit 301086

Finding 390169 (2023-002)

Material Weakness 2023

Capital Region Medical Center

MO

Questioned Costs Allowable Costs / Cost Principles Reporting

Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1,...

Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1, 2024.

View Audit 301083 Questioned Costs: $1

Finding 390163 (2023-005)

Material Weakness 2023

Yukon Flats School District

AK

Cash Management Material Weakness Reporting

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calenda...

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calendar developed by ALASBO which addresses all reporting requirements for the school districts in Alaska. Proposed Completion Date: March 31, 2024

View Audit 301080

Finding 390145 (2023-001)

Significant Deficiency 2023

Health Care for All, INC

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with the Uniform Guidance. This exercise is anticipated to be complete by the end of the fiscal year.

View Audit 301052

Finding 390143 (2023-001)

Significant Deficiency 2023

Nueva Esperanza, Inc.

PA

Reporting § 200.327

Management acknowledges the late filing of SF-425 for direct HUD grants. The delay is due to a delay from the sub awardees providing information timely to Housing Counseling for the fiscal year. Maria Iannarelli, Program Manager for Housing Counseling Assistance Program will continue to communicate ...

Management acknowledges the late filing of SF-425 for direct HUD grants. The delay is due to a delay from the sub awardees providing information timely to Housing Counseling for the fiscal year. Maria Iannarelli, Program Manager for Housing Counseling Assistance Program will continue to communicate with the sub-grantees to ensure reporting on a timely basis.

View Audit 301048

Finding 390138 (2023-002)

Material Weakness 2023

Barnes-Kasson County Hospital

PA

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2023-002 Condition The Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Hospital erroneously entered information into the lost revenue calculation, resulting in lost revenues being understated $1,020,0...

Finding 2023-002 Condition The Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Hospital erroneously entered information into the lost revenue calculation, resulting in lost revenues being understated $1,020,030. The Hospital reported lost revenues amounting to $999,172 on distributions totaling $1,177,041. The Hospital had excess lost revenues from previous periods available to be used through June 30, 2023 amounting to $5,406,884. The Hospital also reported expenses of $907,051. Corrective Action Plan Corrective Action Planned: The Hospital will undertake a review of its internal control policies and procedures surrounding the reporting on federal grant activities and add additional layers of review where necessary to ensure future reporting is accurate. Name of Contact Person Responsible for Corrective Action: Kelli Kane, Chief Financial Officer Anticipated Completion Date: April 15, 2024

View Audit 301031

Finding 390135 (2023-101)

Material Weakness 2023

Gila County

AZ

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Assistance Listings number and program name: 21.027 COVID-19 Corona Virus State and Local Fiscal Recovery Fund Contact: Maryn Belling Anticipated completion date: June 30, 2024 Corrective Action Plan: The County will develop, implement, and maintain procedures requiring both the performance & doc...

Assistance Listings number and program name: 21.027 COVID-19 Corona Virus State and Local Fiscal Recovery Fund Contact: Maryn Belling Anticipated completion date: June 30, 2024 Corrective Action Plan: The County will develop, implement, and maintain procedures requiring both the performance & documentation of independent review and approval of all federal program reports prior to submitting them to the federal agency to ensure the reports are accurate, agree to County records, and contain only allowable expenditures. Program expenditures will be reconciled to the County’s accounting records. The County’s previous corrective action plan stated “Errors identified will be reported to the federal agency in adjusted or resubmitted reports” however the Federal Reporting interface lacks capacity for resubmitted reports. The adjusted reports resulted in the understatement and overstatement amounts noted in Federal Award Finding 2023-101. Departmental training will be provided for staff responsible for preparing and reviewing reports for both data management, compliance with Uniform Guidance, 2 Code of Federal Regulations (CFR) §200.510, and adherence to County’s policies and procedures.

View Audit 301026

Finding 390126 (2023-003)

Material Weakness 2023

San Francisco Community College District

CA

Allowable Costs / Cost Principles Student Financial Aid Subrecipient Monitoring § 200.430

The district Information Technology Services unit is currently working with Ellucian to configure and implement the Time and Effort reporting module within the BANNER timekeeping system. This will allow departments to monitor time and effort activity and ensure that allowable costs are tracked and c...

The district Information Technology Services unit is currently working with Ellucian to configure and implement the Time and Effort reporting module within the BANNER timekeeping system. This will allow departments to monitor time and effort activity and ensure that allowable costs are tracked and charged to the appropriate programs and services. This should be completed by June 30, 2024.

View Audit 301013

Finding 390105 (2023-001)

Significant Deficiency 2023

Invisible Children, Inc.

DC

Subrecipient Monitoring Reporting

Views of Responsible Officials and Planned Corrective Actions: The Organization made every effort to register subawards in excess of $30,000 with the Federal Funding Accountability and Transparency Act Subaward Reporting System. However, due to the change from DUNS to UEI by the federal government a...

Views of Responsible Officials and Planned Corrective Actions: The Organization made every effort to register subawards in excess of $30,000 with the Federal Funding Accountability and Transparency Act Subaward Reporting System. However, due to the change from DUNS to UEI by the federal government and the requirement to use an organization’s UEI to find sub-awardees in FSRS.gov, the Organization was not able to register the subawards meeting the requirements. The Organization is still working with our sub-awardees to establish and collect UEI’s for each so this reporting can be completed this year.

View Audit 300993

Finding 390096 (2023-004)

Material Weakness 2023

Early Childhood Learning Center of Greene County

NY

Reporting

ECLC did request copies of the submitted financial report SF 425 from HHS and to date have not received a response. Effective immediately, the Fiscal Specialist will retain copies of the supporting submission dates in the future, if reports should need to be filed.

View Audit 300988

Finding 390092 (2023-003)

Material Weakness 2023

Early Childhood Learning Center of Greene County

NY

Reporting § 200.512

ECLC is down to 2 employees consisting of the Executive Director and fiscal specialists. ECLC CFO resigned in April of 2022 and ECLC has not been able to fill that position since that time. UHY consultants have been obtained March 24, 2023 and they are helping with the fiscal process. The effect of ...

ECLC is down to 2 employees consisting of the Executive Director and fiscal specialists. ECLC CFO resigned in April of 2022 and ECLC has not been able to fill that position since that time. UHY consultants have been obtained March 24, 2023 and they are helping with the fiscal process. The effect of operating without a CFO has caused delays in preparing financials. ECLC has relinquished the Head Start Grant effective June 30, 2023, and is in the process of dissolution.

View Audit 300988

Finding 390087 (2023-001)

Significant Deficiency 2023

University of Arkansas for Medical Sciences

AR

Reporting Internal Control / Segregation of Duties

Corrective Action Plan Finding 2023-001 Due to the prior year finding, management set a goal to ensure reporting deadlines are met by hiring an additional grants accounting staff member dedicated to monitor the head start program regulations and ensure reports are completed and filed timely. Grants...

Corrective Action Plan Finding 2023-001 Due to the prior year finding, management set a goal to ensure reporting deadlines are met by hiring an additional grants accounting staff member dedicated to monitor the head start program regulations and ensure reports are completed and filed timely. Grants accounting staff planned to utilize checklist functionality in the new financial system that will send required task notifications prior to reporting due dates to assist in meeting reporting deadlines. A new staff member was hired in July 2023. The responsibilities of the new staff member required several months of training and additional time to reconcile the head start accounts causing the January 30, 2023, report to be filed 3 days late. New processes have been implemented where the staff member assigned to the head start program meets weekly with the head start finance manager and director to discuss expenses allocated to the grants, assign tasks to be complete each week, and discuss reporting needs and deadlines. The new implemented processes have proven to assist in proper oversight and accurate financial management of the grants and allowed us to meet the last reporting deadline in November 2023. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: Implemented

View Audit 300960

Finding 390084 (2023-004)

Significant Deficiency 2023

Aims College District

CO

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Condition: We identified one instance where a student’s program enrollment effective date did not match the institution’s records. Recommendation: We recommend that the College enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party se...

Condition: We identified one instance where a student’s program enrollment effective date did not match the institution’s records. Recommendation: We recommend that the College enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The College will review enrollment reporting procedures to determine where additional review of data and monitoring of third-party servicer data can be implemented to ensure accurate reporting. Name(s) of the contract person(s) responsible for corrective action: Chris Peterson – Director of Student Financial Aid, Stacy Sharp – Director of Registration and Records, and Laura Beyers – Director of Registration and Records Planned completion date for corrective action plan: June 30, 2024

View Audit 300954

Finding 390069 (2023-004)

Material Weakness 2023

Gulf Coast Jewish Family and Community Services, INC

FL

Questioned Costs Reporting Material Weakness § 200.502 § 200.510

Management has reviewed the recommendations and will review current and implement new procedures and controls to ensure that all post- award notices received from funding agencies are properly incorporated into the Schedule. Additionally, Management will review reconciliation procedures, and impleme...

Management has reviewed the recommendations and will review current and implement new procedures and controls to ensure that all post- award notices received from funding agencies are properly incorporated into the Schedule. Additionally, Management will review reconciliation procedures, and implement internal controls around the Schedule reconciliation process back to the consolidated financial statements. The corrective action will be implemented no later than June 30, 2024. The primary designated official is Chief Financial Officer.

View Audit 300946 Questioned Costs: $1

Finding 390065 (2023-002)

Significant Deficiency 2023

Vermont Law and Graduate School, Inc. and Subsidiary

VT

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The School will work with its University Accounting Services (UAS) representative to obtain the UAS compliance examination report on a timely basis each year. If UAS is unable to provide the compliance examination report on a timely basis, the School will consider finding another vendor to assist wi...

The School will work with its University Accounting Services (UAS) representative to obtain the UAS compliance examination report on a timely basis each year. If UAS is unable to provide the compliance examination report on a timely basis, the School will consider finding another vendor to assist with the billings, collections and due diligence for the Federal Perkins Loan Program. Responsible Parties: Nathaniel Hibler – Vice President of Finance (802) 831-1204 Emily Parker – General Ledger Accountant (802) 831-1271 Estimated Completion Date: June 30, 2024

View Audit 300926

Finding 390061 (2023-003)

Material Weakness 2023

Ohio Medical Transportation, Inc. D/b/a Medflight of Ohio

OH

Material Weakness Reporting Matching / Level of Effort / Earmarking

Finding Number: 2023-003 Condition: The Corporation reported the incorrect amount of lost revenues for the period 4 portal submission for MedFlight. Planned Corrective Action: Management agrees and ...

Finding Number: 2023-003 Condition: The Corporation reported the incorrect amount of lost revenues for the period 4 portal submission for MedFlight. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure data uploaded into the portal agrees to underlying supporting documentation. Contact person responsible for corrective action: Joe Abel, Chief Financial Officer Anticipated Completion Date: 4/30/2023

View Audit 300923

Finding 390058 (2023-001)

Significant Deficiency 2023

Williams Unified School District No. 2

AZ

Reporting Significant Deficiency

Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Brianne Ford, Business Manager Anticipated Completion Date: March 25, 2024 Planned Corrective Action: The District will monitor and ensure amounts expended a...

Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Brianne Ford, Business Manager Anticipated Completion Date: March 25, 2024 Planned Corrective Action: The District will monitor and ensure amounts expended and reported from the ESSER I, II, & III grants agree to the District's accounting records. The Business Manager and Federal Programs Director will work hand in hand to ensure expended funds are reported accurately.

View Audit 300917

Finding 390049 (2023-002)

Significant Deficiency 2023

Portland State University

OR

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates reported to NSLDS agree to the enrollment effective dates per the University’s records. Explanation of disagreement with audi...

Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates reported to NSLDS agree to the enrollment effective dates per the University’s records. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: It appears that the erroneous enrollment status effective date reported is equal to the certification date for the enrollment file that was sent to the National Student Clearinghouse (NSC). We are researching how the certification date may have been substituted as the enrollment status effective date. Name of the contact person responsible for corrective action: Nicolle DuPont, Associate Registrar Planned completion date for corrective action plan: April 2024

View Audit 300906

Finding 390042 (2023-002)

Significant Deficiency 2023

Ballad Health

TN

Reporting § 200.303 § 200.502 § 200.510

Ballad Health will utilize technology efficiencies within upgraded accounting system to supplement reporting. Additionally, a resource will be added directly responsible for grant accounting. The SEFA will also be reviewed frequently to ensure accuracy.

View Audit 300905

Finding 389996 (2023-001)

None 2023

Washington County Commission on Aging, Inc.

MD

Reporting § 200.512

This incident is an anomaly due to the unanticipated loss of an employee in a small department. The root cause is lack of human capital in the department responsible for the submission of the audit to the Federal Audit Clearinghouse. We acknowledge the importance of adhering to regulatory deadlines ...

This incident is an anomaly due to the unanticipated loss of an employee in a small department. The root cause is lack of human capital in the department responsible for the submission of the audit to the Federal Audit Clearinghouse. We acknowledge the importance of adhering to regulatory deadlines and ensuring the timely submission of these documents. In response to your recommendation, we have already implemented measures to streamline our reporting processes and enhance our internal communication channels to facilitate the timely completion and submission of the required documents. This has involved establishing clear timelines, assigning responsibilities to designated personnel, and implementing monitoring mechanisms to assure that we meet the submission deadlines. The Chief Financial Officer (CFO) was responsible for the submission of the single audit on or before the March 31, 2024 deadline. This will be completed on or before March 31, 2024. The CEO will request board of directors' approval to hire an Executive Finance Officer (EFO) in an effort to increase the depth of the finance department. This will provide coverage during unexpected absenses in an effort to avoid future delays. The board of directors' approved the posting of a new EFO position on September 15, 2023. Position is posted and will remain posted until the position is filled. As soon as the EFO is hired, the CFO and EFO will cross train all duties related to the timely completion of documents to assure the timely submission of the single audit and assure that the Federal Audit Clearinghouse deadline is met. This is pending the hiring of the EFO. The position is currently posted. By October of each year, the CFO or EFO will conduct random sample internal audits or reviews before the single audit submission deadline to ensure documents are accurate and in compliance with federal regulations. Implement plans of correction for any areas identified out of compliance. This process is on-going.

View Audit 300903

Finding 389991 (2023-005)

None 2023

Queens University of Charlotte

NC

Student Financial Aid Period of Performance Reporting

Individual Responsible for Corrective Action: Linda Fleischman, Registrar Corrective Action: The Registrar’s Office will reach out to Jenzabar to determine what is triggering the incorrect program start date. Beginning with the summer 2024 students, each new student record will be reviewed prior to...

Individual Responsible for Corrective Action: Linda Fleischman, Registrar Corrective Action: The Registrar’s Office will reach out to Jenzabar to determine what is triggering the incorrect program start date. Beginning with the summer 2024 students, each new student record will be reviewed prior to the initial National Student Clearinghouse submission to ensure that the start date is being reported correctly. Anticipated Completion Date: August 15, 2024

View Audit 300901

Finding 389979 (2023-008)

Significant Deficiency 2023

Youth & Shelter Services, INC

IA

Reporting

Finance leadership will work with grant managers, grant billers, and program managers to develop a schedule of compliance due dates for report submission to help ensure that all grant programs remain compliant with reporting requirements.

View Audit 300877

Finding 389952 (2023-009)

Significant Deficiency 2023

Youth & Shelter Services, INC

IA

Reporting

As identified, with the change in our lead grant biller, the new grant biller commendably updated the SEFA schedule, but lacked the training to reconcile the schedule to other existing documents and did not present the SEFA schedule to finance leadership for review prior to submission to the auditor...

As identified, with the change in our lead grant biller, the new grant biller commendably updated the SEFA schedule, but lacked the training to reconcile the schedule to other existing documents and did not present the SEFA schedule to finance leadership for review prior to submission to the auditor. This was discussed during review, and finance leadership worked alongside the grant biller, using the reconciliation process as an opportunity to provide training.

View Audit 300877

Corrective Action Plans

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