Corrective Action Plans

Finding 380684 (2023-007)

Significant Deficiency 2023

New American Association of Massachusetts, Inc.

MA

Allowable Costs / Cost Principles Reporting § 200.303

The Organization is implementing stronger procedures and controls surrounding payroll transactions. New procedures will be developed and implemented to ensure timely submission by employees, approval, and proper allocation of employees’ timesheet and related salary costs. The updated procedures, in ...

The Organization is implementing stronger procedures and controls surrounding payroll transactions. New procedures will be developed and implemented to ensure timely submission by employees, approval, and proper allocation of employees’ timesheet and related salary costs. The updated procedures, in part, will include: • Implementing a standard timesheet to be utilized by all employees which must be submitted by the employee, with sufficient evidence it was actually completed by an employee, by a predetermined date each pay period. • Requiring the timesheet to have written approval by a supervisor, or the Executive Director if there is no direct supervisor. • Developing a policy in which hourly employees must request and be approved to work overtime. • Requiring segregation of duties between key functions in the payroll process.

View Audit 295394

Finding 380605 (2023-001)

None 2023

Town of Stow

MA

Subrecipient Monitoring Reporting § 200.1

Condition: Obligations were overstated by $965,175 on the March 31, 2023 Project and Expenditure report. Corrective Action Planned: The overstated obligation error will be corrected in the next federal reporting period. Anticipated Completion Date: April 30, 2024 Contact: Denise M. Dembkoski,...

Condition: Obligations were overstated by $965,175 on the March 31, 2023 Project and Expenditure report. Corrective Action Planned: The overstated obligation error will be corrected in the next federal reporting period. Anticipated Completion Date: April 30, 2024 Contact: Denise M. Dembkoski, Town Administrator

View Audit 295369

Finding 380599 (2023-009)

Material Weakness 2023

Madison-Grant United School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-009 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: Material Weakness, Other Matters, Qualified Opinion The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, tha...

FINDING 2023-009 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: Material Weakness, Other Matters, Qualified Opinion The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were prepared by the Chief Financial Officer and reviewed by a second knowledgeable individual; however, this process did not allow for the prevention, or detection and correction of errors prior to submission. Due to the lack of effective internal controls, one of the six annual data reports was not supported by the School Corporation’s records. For the ESSER 1, Year 2 report, which covered the period of October 1, 2020 to June 30, 2021, the School Corporation’s records did not support the data in the report. The lack of controls and noncompliance were isolated to the ESSER I, Year 2 report. Contact Person Responsible for Corrective Action: Bengamin Mann Contact Phone Number and Email Address: 765-536-0008 bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Supporting documentation of data reported will be retained with each report filed. Anticipated Completion Date: February 2024

View Audit 295346

Finding 380552 (2023-002)

Material Weakness 2023

Kimball County

NE

Reporting Subrecipient Monitoring § 200.302 § 200.303 § 200.502 § 200.510 § 200.511

Program:Various, including AL 20.509 – Formula Grants for Rural Areas and Tribal Transit Program – Reporting Corrective Action Planned: The transit will continue to provide training to all the personnel who handles the information needed to properly calculate the SEFA amounts for future audits. An...

Program:Various, including AL 20.509 – Formula Grants for Rural Areas and Tribal Transit Program – Reporting Corrective Action Planned: The transit will continue to provide training to all the personnel who handles the information needed to properly calculate the SEFA amounts for future audits. Anticipated Completion Date: June 30, 2024 Responsible Party: Christy Warner, Transit Administrator

View Audit 295337

Finding 380548 (2023-002)

Significant Deficiency 2023

River Kourt Apartments

OR

HUD Housing Programs Reporting Significant Deficiency

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HU...

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HUD within 90 days of the fiscal year end. 2. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance, ShelterCare 3. The anticipated completion date: a. New property accountant was hired in August of 2023.

View Audit 295334

Finding 380546 (2023-001)

Material Weakness 2023

Corry Memorial Hospital Association D/b/a Lecom Health Corry Memorial

PA

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Condition The Organization did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Organization erroneously excluded certain transactions from the lost revenue calculation, resulting in lost revenues being overstated $95,765...

Condition The Organization did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Organization erroneously excluded certain transactions from the lost revenue calculation, resulting in lost revenues being overstated $95,765. The Organization reported lost revenues amounting to $471,219 on distributions totaling $925,113. The Organization had excess lost revenues from previous periods available to be used through June 30, 2023 amounting to $1,218,904. Corrective Action Plan Corrective Action Planned: The Organization will update its policies and procedures to ensure the submission undergoes a detailed review and that all points are cleared prior to submission. Name(s) of Contact Person(s) Responsible for Corrective Action: Tim McGahen, Chief Financial Officer Anticipated Completion Date: We anticipate that this will be completed by June 30, 2024.

View Audit 295333

Finding 380499 (2023-001)

Significant Deficiency 2023

Goucher College

MD

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The Office of the Registrar has identified the errors in the National Student Clearinghouse reporting. They have worked internally with our IT department to pinpoint the errors resulting in delays in submission to the National Student Loan Database Systems (NSLDS) via the National Clearinghouse. The...

The Office of the Registrar has identified the errors in the National Student Clearinghouse reporting. They have worked internally with our IT department to pinpoint the errors resulting in delays in submission to the National Student Loan Database Systems (NSLDS) via the National Clearinghouse. The Office of the Registrar is presently completing data review and clean-up. Once this is completed The Office of the Registrar will submit overdue files to the National Clearinghouse in conjunction with the Senior Director of Information Technology to ensure all technical requirements are met. These updates and alignments should bring late reporting to zero. The goal is to have no findings in 2025. Name of Contact Person Responsible for Corrective Action: Debbie Blake, Registrar and Emily Perl, Associate Vice President for Student Success. Anticipated Completion Date: 06/01/2024

View Audit 295275

Finding 380497 (2023-002)

Significant Deficiency 2023

The Children's Home of Poughkeepsie, Inc.

NY

Reporting

Planned Corrective Action: CHP underwent a transition in Fiscal leadership during this fiscal year. In addition, CHP was assigned a new Grant Management Specialist that rejected FFR reports for missing information that was not previously provided. Corrections were made following the rejections and...

Planned Corrective Action: CHP underwent a transition in Fiscal leadership during this fiscal year. In addition, CHP was assigned a new Grant Management Specialist that rejected FFR reports for missing information that was not previously provided. Corrections were made following the rejections and the resubmission dates were updated with the latter date. CHP will continue to utilize a recurring calendar reminder.

View Audit 295260

Finding 380441 (2023-001)

Significant Deficiency 2023

Ventura County Community College District

CA

Student Financial Aid Special Tests & Provisions Reporting

II. FEDERAL FINDINGS AND QUESTIONED COSTS 2023-001 Special Tests and Provisions Management's Response: We concur. View of Responsible Officials and Corrective Action Plan The District reviewed past practices and implemented revised procedures to ensure accurate student enrollment information is...

II. FEDERAL FINDINGS AND QUESTIONED COSTS 2023-001 Special Tests and Provisions Management's Response: We concur. View of Responsible Officials and Corrective Action Plan The District reviewed past practices and implemented revised procedures to ensure accurate student enrollment information is reported to the National Student Loan Data System. Additionally, the District consulted with the National Student Clearinghouse and prior semesters’ enrollment information was revised and resubmitted. Name of responsible individual: John Cooney Implementation Date: October 26, 2023

View Audit 295216

Finding 380432 (2023-002)

Material Weakness 2023

Michigan State University

MI

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

Finding Number: 2023-002 Condition: The University used inaccurate or incomplete data in the return of Title IV calculations. Planned Corrective Action: The failure to return funds in a timely fashion is primarily a result of university withdrawal policy not aligning with the timelines required by t...

Finding Number: 2023-002 Condition: The University used inaccurate or incomplete data in the return of Title IV calculations. Planned Corrective Action: The failure to return funds in a timely fashion is primarily a result of university withdrawal policy not aligning with the timelines required by the regulations. To that end, the university is revising its policies and procedures, specifically as they relate to “medical withdrawals” and for programs where attendance is required. As of June 2023, the University now has reports that identify all the affected students in a timely fashion. Additional resources have been allocated to assure that there is consistency and timeliness in the review of enrollment data specifically as it relates to determining attendance in dropped courses, and students who rescind their intent to withdraw, or enroll in or attend subsequent modules. Contact person responsible for corrective action: Steve Shablin - University Registrar, Matthew Lyth - Financial Aid Officer Anticipated Completion Date: 05/10/2024

View Audit 295211 Questioned Costs: $1

Finding 380427 (2023-001)

Material Weakness 2023

Michigan State University

MI

Student Financial Aid Material Weakness Reporting

Finding Number: 2023-001 Condition: The University did not report the status changes of certain students to the NSLDS in an accurate and timely manner during the fiscal year. Planned Corrective Action: The University is submitting the data to NSLDS via the Clearinghouse in the required timeline. Cer...

Finding Number: 2023-001 Condition: The University did not report the status changes of certain students to the NSLDS in an accurate and timely manner during the fiscal year. Planned Corrective Action: The University is submitting the data to NSLDS via the Clearinghouse in the required timeline. Certain status changes took place after the standard reporting cycle and were not picked up in this process. New processes have been established to identify and report these status changes to NSLDS that take place after the standard reporting cycle. Contact person responsible for corrective action: Becky Keogh, Senior Associate Registrar Anticipated Completion Date: 05/10/2024

View Audit 295211

Finding 380419 (2023-001)

Material Weakness 2023

Milwaukee Institute of Art and Design, Inc.

WI

Reporting Special Tests & Provisions Student Financial Aid

Corrective Action Plan For the Year Ended May 31, 2023 Finding 2023-001 Assistance Listing Number(s), Federal Agency and Program Name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial assistance cluster. Finding Type: Noncompliance and material weakn...

Corrective Action Plan For the Year Ended May 31, 2023 Finding 2023-001 Assistance Listing Number(s), Federal Agency and Program Name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial assistance cluster. Finding Type: Noncompliance and material weakness in internal control over compliance relating to special tests. Criteria: The Institute is responsible for designing, implementing, and maintaining internal control over compliance for special tests and provisions and for accurately and timely reporting significant data elements under the Campus- Level and Program-Level records within the National Student Loan Data System (NSLDS) that DOE considers high risk. Statement of Condition: Management implemented controls that specifically addressed the circumstances surrounding prior year finding 2022-001. Management's review of the enrollment reporting did not detect other errors on certain student data elements or timely reporting. Certain student records within the NSLDS were identified with inaccurate data elements and not timely reported. Questioned Costs: Questioned costs could not be determined. Context: 10 students were identified with inaccurate data elements and not timely reported out of a total of 25 students tested. Cause: The Institute’s internal control over compliance did not detect and correct the errors. The preparer incorrectly input the student's effective date and status into NSLDS resulting in inaccuracies in significant Campus- Level and Program-Level enrollment data elements that DOE considers high risk. Effect: The Institute incorrectly reported certain Campus-Level and Program-Level records in NSLDS which is information that DOE considers high risk and the Institute’s internal controls over compliance did not detect and correct the errors. Recommendation: We recommend management review policies and procedures surrounding enrollment reporting submissions to ensure the accuracy of data elements reported to DOE. A review performed by an appropriate individual separate from the preparer prior to the submission of the enrollment reports to NSLDS may improve the accuracy of enrollment reporting. Status: Completed February 2024 Corrective Action: Management agrees with the finding. Through internal investigation, it was determined that there was a procedural issue with the manual entry of two date fields which both need to be the same when submitted to National Student Clearinghouse (NSC). Human error during these manual checks caused one data field to be correct, and the other incorrect. This error has been fixed so that both fields will always be the same and accurate. We have also updated our enrollment reporting procedures to have the registrar log into NSLDS monthly to confirm that the prior month NSC status changes are properly recorded in NSLDS. Contact Jean Weimer Registrar 414-847-3272 jeanweimer@miad.edu Submitted Feb 23, 2024

View Audit 295200

Finding 377382 (2023-006)

Significant Deficiency 2023

University of California

CA

Reporting § 200.502 § 200.510

2023-006 – Completeness and accuracy of certain programs on the Prior Year Schedules of Expenditures of Federal Awards (SEFA) - (Significant Deficiency) Cluster: Not applicable Sponsoring Agency: Department of Health and Human Services (DHHS) - Health Resources and Services Administration (HRSA), D...

2023-006 – Completeness and accuracy of certain programs on the Prior Year Schedules of Expenditures of Federal Awards (SEFA) - (Significant Deficiency) Cluster: Not applicable Sponsoring Agency: Department of Health and Human Services (DHHS) - Health Resources and Services Administration (HRSA), Department of Education (ED) and Federal Emergency Management Agency (FEMA) Award Names: COVID-19 Provider Relief Fund and ARP (ARP) Rural Distribution (PRF), COVID-19 Higher Education Emergency Relief Fund (HEERF) Student Portion, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) and Maternal and Child Health Federal Consolidated Programs Award Numbers: Various Assistance Listing Titles: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters), COVID-19 Higher Education Emergency Relief Fund (HEERF) Student Aid Portion, COVID-19 HEERF Institutional Aid Portion, COVID-19 HEERF Minority Serving Institutions, and Maternal and Child Health Federal Consolidated Programs Assistance Listing Number: 93.498, 97.036, 84.425E, 84.425F, 84.425L, 93.110 Award Year: 2020-2021, 2021-2022, 2019-2020, 2021-2023 Pass-through entity: Not applicable Management has implemented additional reconciliation and review procedures over the last two years to improve the accuracy and completeness of the SEFA. · UCOP implemented an annual SEFA review process to include the systemwide Controller and campus Controllers. UCOP also distributed one interim SEFA draft to the External Fund Managers (EFMs) that had historically been tasked with only a year-end review. · UCOP continued to reconcile atypical federal programs (e.g., PRF, FEMA, etc.) and included in the fiscal year 2023 SEFA drafts for campus Controller review. Beginning in FY 2024, UCOP will implement more comprehensive financial reporting controls as follows: · Interim SEFA reports, inclusive of atypical programs, will be prepared centrally and distributed to campuses for review and alignment with campus records. Campus management will be tasked with the responsibility for overall review and signoff for both interim and final SEFA reports. · The Systemwide Controller will also be included in the review process by performing an overall review and signoff for both interim and final SEFA reports. With respect to the specific findings in FY2023 for atypical / nonrecurring federal programs, the following actions have been and/or will be taken: • FEMA: A reconciliation process was implemented within UCOP in FY2023, the result of which was the discovery of the understatement referenced in the finding. FEMA expenses are now reconciled to, and obligation dates retrieved from, the Federal FEMA Grants Portal to ensure project expenses are accurately reported in the proper fiscal year. Data from the State portal is distributed to campuses for validation. UCOP has also reminded campus and medical center Controllers of the reporting requirements and will cover this topic again in future trainings. Additionally, UCOP will remind campuses and medical centers of the requirement to account for the FEMA project in the federal fund range at the time of obligation to trigger SEFA reporting. • PRF – A reconciliation process was implemented by UCOP in FY2022 and the reconciliation itself was completed in FY2023, the result of which was the discovery of the understatement referenced in the finding. PRF expenses reported by campuses are now reconciled to the HRSA online portal which will continue for the duration of the program. UCOP has also reminded campus and medical center Controllers of their responsibility to report on these dollars for their entire enterprise (Faculty Practice Group, School of Medicine, etc.). As with all other federal funding, PRF amounts will continue to be part of the SEFA reports distributed to campuses for review and signoff. Coordination between campuses and medical centers will be expected for this review and signoff. • HEERF – while the program ended in FY2023, UCOP will apply lessons learned to any future “special” funding. When atypical programs such as this are awarded in the future, UCOP will provide more consistent guidance upfront and establish more consistent accounting and reporting requirements for campuses and the medical centers to follow. Requirements will include regular reporting of these dollars to UCOP with a reconciliation of campus ledgers to any sponsor reporting. As with all other federal funding, amounts will be part of the SEFA reports distributed to campuses for review and signoff. • Program Income – UCOP will develop and conduct expanded training to campus Controllers, EFMs and their staff to include SEFA requirements generally, including treatment for program income (and other SEFA exclusions), new review procedures, etc. UCOP will target training for the spring of 2024. For inquiries regarding this finding, please contact Barbara Cevallos at barbara.cevallos@ucop.edu who is responsible for the corrective action.

View Audit 295197

Finding 377379 (2023-002)

None 2023

University of California

CA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting

2023-002 – Transfer of costs from HEERF to FEMA not reported in HEERF quarterly report Cluster: Not applicable Sponsoring Agency: Department of Education (ED) Award Name: COVID-19 Higher Education Emergency Relief Fund (HEERF) – Institutional Portion Award Number: P425F202631 - 20B Assistance ...

2023-002 – Transfer of costs from HEERF to FEMA not reported in HEERF quarterly report Cluster: Not applicable Sponsoring Agency: Department of Education (ED) Award Name: COVID-19 Higher Education Emergency Relief Fund (HEERF) – Institutional Portion Award Number: P425F202631 - 20B Assistance Listing Title: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425F Award Year: 2020-2021 Pass-through entity: Not applicable The campus amended the March 31, 2021, quarterly HEERF institutional report by prominently highlighting the modifications. • A revised report has been uploaded to the campus website (UCLA Financial Aid and Scholarships – HEERF Institutional Portion Reports) alongside the other completed quarterly HEERF reports. • In accordance with ED guidelines, the old report has been replaced with the updated version, clearly indicating the date of the revision. For inquiries regarding this finding, please contact Selina Martin at selinamartin@finance.ucla.edu who is responsible for the corrective action.

View Audit 295197

Finding 377368 (2023-001)

Material Weakness 2023

Cloverdale Community School Corporation

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

FINDING 2023-001 Finding Subject: Education Stabilization Fund - Internal Controls Over Annual Data Report Summary of Finding: Significant Deficiency; A failure to establish an effective internal control system creating a risk of noncompliance with the grant agreement and the reporting compliance r...

FINDING 2023-001 Finding Subject: Education Stabilization Fund - Internal Controls Over Annual Data Report Summary of Finding: Significant Deficiency; A failure to establish an effective internal control system creating a risk of noncompliance with the grant agreement and the reporting compliance requirement. Contact Person Responsible for Corrective Action: Mendy Shrout Contact Phone Number and Email Address: 765-795-4664 mshrout@cloverdale.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: NA Description of Corrective Action Plan: Management has created a google doc to record the reviewed by and submitted by dates of the reporting. As well as including financial reports in respective report files. Anticipated Completion Date: Google doc was created February 5, 2024

View Audit 295157

Finding 377339 (2023-001)

Material Weakness 2023

Edgewood College, Inc.

WI

Special Tests & Provisions Student Financial Aid Reporting

Finding: Management's review of the enrollment reporting did not detect errors on certain student data elements. Certain student records within the NSLDS were identified with inaccurate data elements. The College is responsible for designing, implementing, and maintaining internal control over compl...

Finding: Management's review of the enrollment reporting did not detect errors on certain student data elements. Certain student records within the NSLDS were identified with inaccurate data elements. The College is responsible for designing, implementing, and maintaining internal control over compliance for special tests and provisions and for accurately reporting significant data elements under the Campus-Level and Program-Level records within the National Student Loan Data System (NSLDS) that the Department of Education (ED) considers high risk. The College's internal control over compliance for special tests are not operating effectively. The preparer did not update the student's status into NSLDS resulting in inaccuracies in significant Campus-Level and Program-Level enrollment date elements that ED considers high risk. Additionally, student with status changes were incorrectly reported as withdrawn but upon review of internal documentation, those same students graduated. We recommend management review and enhance its review policies and procedures surrounding enrollment reporting submissions to ensure the accuracy of data elements reported to ED. A review performed by an appropriate individual separate from the prepared prior to the submission of the enrollment reports to NSLDS may improve the accuracy of enrollment reporting. We also recommend management review all students reported to NSLDS to verify they are accurately reported. Corrective Action: Management agrees and has implemented necessary procedures/controls to ensure the College is in compliance with enrollment requirements.

View Audit 295133

Finding 377325 (2023-001)

Material Weakness 2023

Horizon Health and Wellness, Inc.

AZ

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #860554593 Reporting Material Weakness in Internal Control Over Compliance and Material N...

Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #860554593 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The Organization selected option iii to calculate lost revenue using budgeted gross revenues to actual gross revenues. The Organization’s HHS Period 4 Report included lost revenues for three quarters that did not agree to the supporting calculation of lost revenues. Without proper implementation of internal controls over the Organization’s budget prior to submission errors could occur resulting in the Organization not calculating lost revenues correctly. Status: The Organization will be adopting a policy to enhance internal controls over the budget to ensure that the lost revenue calculation is not changed after submission and follows the option iii methodology utilized to calculate lost revenues. Responsibility of: Richard Leonard (Controller) and Andrew Horan (Director of F.P. and A.) Estimated Completion Date: 3/31/24

View Audit 295119

Finding 377318 (2023-001)

Material Weakness 2023

Sarasota County, Florida

FL

Subrecipient Monitoring Material Weakness Reporting § 200.303

Material Weakness - Internal Controls over Reporting and Noncompliance The Office of Financial Management (OFM) Grant Program Administrator, Heather Larson will monitor and ensure that Federal Funding Accountability and Transparency Act of 2006 (FFATA) reports are filed as required in the FSRS syste...

Material Weakness - Internal Controls over Reporting and Noncompliance The Office of Financial Management (OFM) Grant Program Administrator, Heather Larson will monitor and ensure that Federal Funding Accountability and Transparency Act of 2006 (FFATA) reports are filed as required in the FSRS system. Since the recent transition of the CDBG Entitlement Cluster from an outside agency back to Sarasota County, the County has implemented a standardized form to capture needed information from current and future subrecipients to report appropriately the requirements of the Federal Funding Accountability and Transparency Act of 2006 (FFATA). The OFM Grant Analyst assigned to the funding award, upon review of any pending subaward/ subaward amendment, will create an Action Item utilizing the Grants Administration module of OnBase. The Action Item will require completion of any required FSRS reporting. Action item will be assigned and have a deadline date no late than the last day of the month following the month in which the subaward/ subaward amendment obligation was made. Implementation date for this process - On or before February 28, 2024.

View Audit 295115

Finding 377305 (2023-006)

Significant Deficiency 2023

Floyd County Medical Center

IA

Reporting Significant Deficiency

Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Preparati...

Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards ‐ Other Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate Schedule being audited. Eide Bailly, LLP, the auditors, were requested to draft the Schedule and notes to the Schedule. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Management agrees with this finding. Management will develop and implement an internal control system tailored to ensure completeness and accuracy in auditing the Schedule. Management will clearly define the objectives of the internal control system to address gaps in auditing procedures. Management will set clear standards and protocols for auditing processes, ensuring adherence to regulatory requirements. Management will provide comprehensive training to staff involved in auditing processes to ensure they understand their roles and responsibilities. Management will conduct regular assessments and reviews of the internal control system's effectiveness and make adjustments as needed to improve accuracy and completeness. Anticipated Completion Date: 2/26/2024.

View Audit 295111

Finding 377304 (2023-005)

Significant Deficiency 2023

Floyd County Medical Center

IA

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting...

Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: There was no evidence retained that the Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN #420868216 was reviewed or approved by an individual separate from the preparer prior to submission. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Management agrees with this finding. Management will designate specific individuals to review HHS special report submissions before submission to HHS. Management will require documentation verifying independent review and approval prior to submission. Management will provide comprehensive training to staff on the importance of independent review processes. Management will set up automated workflow systems and checklists to enforce review procedures. Management will regularly audit the review process, gather feedback, and make necessary adjustments for enhancement. Anticipated Completion Date: 2/26/2024.

View Audit 295111

Finding 377298 (2023-109)

Significant Deficiency 2023

Commonwealth of Virginia

VA

Subrecipient Monitoring Reporting Significant Deficiency

Responsible Contact Person(s): Kassandra Bullock, Director of Grants Management DeAndrea Williams, Grants Admin Supervisor Joseph Thompson, Grants Compliance Supervisor John Colligan, Director of Finance and Administration Corrective Action Planned: An internal compliance review has been implemented...

Responsible Contact Person(s): Kassandra Bullock, Director of Grants Management DeAndrea Williams, Grants Admin Supervisor Joseph Thompson, Grants Compliance Supervisor John Colligan, Director of Finance and Administration Corrective Action Planned: An internal compliance review has been implemented to ensure accuracy and timely reporting of FFATA data. Data is confirmed prior to upload by the Grants Compliance Team to address errors, missing information, and conflicting dates. Training has occurred via the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) by Grants Admin staff. Additionally all changes in statements of grant awards (SOGA) will be reviewed and reissued when needed and data re-entered to ensure FFATA correlates with SOGA. Estimated Completion Date: 1/26/2024

View Audit 295106

Finding 377290 (2023-107)

Significant Deficiency 2023

Commonwealth of Virginia

VA

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

Responsible Contact Person(s): Ida Witherspoon, Chief Financial Officer Corrective Action Planned: Send periodic e-mail reminders to program staff responsible for submitting FFATA data to the Federal Reporting Unit for submission to the federal government. Additional time is needed to fully impleme...

Responsible Contact Person(s): Ida Witherspoon, Chief Financial Officer Corrective Action Planned: Send periodic e-mail reminders to program staff responsible for submitting FFATA data to the Federal Reporting Unit for submission to the federal government. Additional time is needed to fully implement an automated solution. Estimated Completion Date: 10/30/2024

View Audit 295106

Finding 377287 (2023-106)

Significant Deficiency 2023

Commonwealth of Virginia

VA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS will perform an analysis of identified reporting errors to determine causality and the appropriate actions to resolve reporting errors. Additio...

Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS will perform an analysis of identified reporting errors to determine causality and the appropriate actions to resolve reporting errors. Additionally, DSS will create a systems modification request to correct errors that are identified as occurring as a result of inaccurate programming in the data modification phase of federal report creation. Estimated Completion Date: 12/31/2024

View Audit 295106

Finding 377284 (2023-105)

Material Weakness 2023

Commonwealth of Virginia

VA

Subrecipient Monitoring Material Weakness Reporting

Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Mark Golden, Economic Assistance and Employment Manager Division of Benefit Programs Corrective Action Planned: Perform an analysis of identified reporting errors to determine causality and the appropriate actions to resolve r...

Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Mark Golden, Economic Assistance and Employment Manager Division of Benefit Programs Corrective Action Planned: Perform an analysis of identified reporting errors to determine causality and the appropriate actions to resolve reporting errors. Create a systems modification request to correct errors that are identified as occurring as a result of inaccurate programming in the data modification phase of federal report creation. Estimated Completion Date: 6/30/2024

View Audit 295106

Finding 377283 (2023-104)

Material Weakness 2023

Commonwealth of Virginia

VA

Eligibility Material Weakness Period of Performance § 200.303 § 200.501

Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS has requested the vendor's records. Once received, DSS will audit those records to provide reasonable assurance that the contractor administer...

Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS has requested the vendor's records. Once received, DSS will audit those records to provide reasonable assurance that the contractor administered the LIHWAP federal grant program in accordance with federal statutes, regulations, and the terms and conditions of the federal award before it closes the grant award. Estimated Completion Date: 6/30/2024

View Audit 295106

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