Corrective Action Plans

Finding 382745 (2023-001)

Significant Deficiency 2023

KY

Reporting

As part of its processes and procedures to prepare the SEFA, management will reach out to the funding source (mentioned above) to verify the source of the funds to ensure the accuracy of reported federal expenditures. Additionally, for the specific funding agreement (mentioned above), management wi...

As part of its processes and procedures to prepare the SEFA, management will reach out to the funding source (mentioned above) to verify the source of the funds to ensure the accuracy of reported federal expenditures. Additionally, for the specific funding agreement (mentioned above), management will reach out to the related funding source to communicate the discrepancy (the funding agreement’s source of funds is not consistent funds received).

View Audit 296347

Finding 382744 (2023-001)

Significant Deficiency 2023

Realife Cooperative of Phalen Village

MN

Reporting Internal Control / Segregation of Duties

Housing and Urban Development Realife Cooperative of Phalen Village respectfully submits the following corrective action plan for the yeqr ended December 31, 2023. Westberg Eischens, PLLP 2630 1 st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: December 31, 2023 The finding from the Decem...

Housing and Urban Development Realife Cooperative of Phalen Village respectfully submits the following corrective action plan for the yeqr ended December 31, 2023. Westberg Eischens, PLLP 2630 1 st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: December 31, 2023 The finding from the December 31, 2023 schedule of findings and questioned costs and the summary schedule of prior audit findings is discussed below. The finding is numbered consistently with the number assigned in the schedules. Summary of audit results does not include findings and is not addressed. Finding 2023-001 Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 296344

Finding 382736 (2023-007)

Material Weakness 2023

City of Mandeville, Louisiana

LA

Reporting

PROCEDURES OVER PREPARATION OF THE SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS The City of Mandeville has hired Melissia O’Neil, Executive Assistant to the Mayor. She is experienced in this field and is helping to ensure that the information and balances that are accumulated and reported are accurate...

PROCEDURES OVER PREPARATION OF THE SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS The City of Mandeville has hired Melissia O’Neil, Executive Assistant to the Mayor. She is experienced in this field and is helping to ensure that the information and balances that are accumulated and reported are accurate. This has already begun.

View Audit 296327

Finding 382733 (2023-001)

Significant Deficiency 2023

Fisher College

MA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Corrective Action Plan To ensure complete and comprehensive National Student Loan Data System (“NSLDS”) reporting compliance as outlined in 34 CFR 685.309(b)(2) and in 2 CFR Part 200, Appendix XI Compliance Supplement, the College undertook a review of its trainings and procedures. Within that revie...

Corrective Action Plan To ensure complete and comprehensive National Student Loan Data System (“NSLDS”) reporting compliance as outlined in 34 CFR 685.309(b)(2) and in 2 CFR Part 200, Appendix XI Compliance Supplement, the College undertook a review of its trainings and procedures. Within that review, areas of inconsistencies were identified relative to status changes and timely reporting. Acknowledging that the current procedures were not adequate, the College has implemented additional trainings and reconciliation procedures, as recommended. Revised trainings to the College employees responsible for processing information for the NSLDS will henceforth include, but not be limited to, an annual review of both the NSLDS Enrollment Reporting Guide and the National Student Clearinghouse Enrollment Overview. Such trainings will emphasize the importance of reporting accuracy and timeliness. The College has also updated reconciliation procedures for enrollment reporting and added the implementation of a secondary review of monthly enrollment submissions by the Director of Title IV Compliance. Timeline for Implementation of Corrective Action Plan Effective immediately. Contact Person Colleen Woods, Director of Title IV Compliance

View Audit 296325

Finding 382707 (2023-003)

Material Weakness 2023

Ou Medicine, Inc.

OK

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Period of Performance

Corrective Action Plan Finding 2023-003 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA); Assistance Listing ...

Corrective Action Plan Finding 2023-003 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA); Assistance Listing No. 93.498, Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions Condition: Per discussion with management, OU Medicine, Inc. has processes and internal controls in place to comply with the terms and conditions of the award and the reporting requirements. However, management did not retain documentation evidencing the performance of these controls. Corrective Action: At the beginning of the pandemic, OU Health created working groups to evaluate the requirements for COVID-19 funding received and ensure the funds were only used for allowable purposes. The working groups were assisted by outside consultants to stay updated on the reporting requirements as the continued to evolve. As part of the Uniform Guidance audit, OU Health provided documentation of the Provider Relief Fund review process that explained how eligible costs were identified and submitted. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will develop a checklist to document the review and approval of supporting documentation of contract labor costs as reported federal expenditures. The supporting documentation will be reviewed by management to ensure expenses charged to the federal program are allowable and have not been reimbursed under another federal program. The checklist will be retained with the existing report. Responsible Official: Bernard Githinji, AVP Corporate Controller Anticipated Completion Date: April 30, 2024

View Audit 296298

Finding 382689 (2023-006)

Material Weakness 2023

Muncie Community Schools

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

Finding 2023-006 – Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ESSER reports include accurate...

Finding 2023-006 – Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ESSER reports include accurate information that agree to the underlying disbursement records. Anticipated Completion Date: Next ESSER reports due in FY24

View Audit 296252

Finding 382645 (2023-002)

Significant Deficiency 2023

San Joaquin Delta Community College District

CA

Student Financial Aid Reporting Significant Deficiency

The Admissions & Records Department discovered that there was an error in our reporting. The issue is that the wrong field was being picked up by NSLDS because our report was not pulling the correct data field. This has been corrected by the District IT department. We also discovered that although w...

The Admissions & Records Department discovered that there was an error in our reporting. The issue is that the wrong field was being picked up by NSLDS because our report was not pulling the correct data field. This has been corrected by the District IT department. We also discovered that although we reported the correct data to the National Clearinghouse, it never transferred over to NSLDS. We will reach out to the Clearinghouse to ensure that this will not occur again. We also discovered that with one student enrollment issue, the college did not follow the correct process so that the report did not pick up the student enrollment. This has been resolved by providing staff with appropriate training. The director has and will continue to provide ongoing training.

View Audit 296241

Finding 382634 (2023-001)

Material Weakness 2023

West River Area Health Education Center

SD

Reporting Internal Control / Segregation of Duties

Finding No. 2023-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Stephanie Mayfield, Executive Director Corrective Action Plan: It is more cost effective for the Organization to hire Ketel Thorstenson, LLP, a public accounting firm,...

Finding No. 2023-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Stephanie Mayfield, Executive Director Corrective Action Plan: It is more cost effective for the Organization to hire Ketel Thorstenson, LLP, a public accounting firm, to prepare the full disclosure financial statements as a part of the annual audit process. The Organization has designated a member of management to review the draft financial statements and accompanying notes to the financial statements. The Organization has accepted the risk associated with the finding regarding the preparation of the financial statements, and will continue to have the independent auditor prepare the annual financial statements. Anticipated Completion Date: Ongoing

View Audit 296216

Finding 382630 (2023-002)

Significant Deficiency 2023

Olivet Nazarene University

IL

Reporting Matching / Level of Effort / Earmarking Student Financial Aid § 200.303

The University understands the importance of returning Title IV funds within the established federal timeframe guidelines. This incident occurred as a result of the student stopping attendance without going through the proper channels to notify the university of their intention to withdraw. The staf...

The University understands the importance of returning Title IV funds within the established federal timeframe guidelines. This incident occurred as a result of the student stopping attendance without going through the proper channels to notify the university of their intention to withdraw. The staff attempted to contact the student to clarify the reason for their absence but was not able to do so until after the holiday break. The staff have been instructed to make as many attempts as it takes to resolve the question of a student’s unofficial withdrawal within the required timeframes. Trisha O’Brien will ensure the process of communicating with the student is followed. This should reduce the chance of the finding in the future.

View Audit 296208

Finding 382629 (2023-001)

Significant Deficiency 2023

Olivet Nazarene University

IL

Student Financial Aid Reporting Matching / Level of Effort / Earmarking § 200.303

The University understands the importance of timely exit counseling. The reporting structure for the January, 2023 determination of students not returning from the holidays did not work properly, and the university has corrected the process. Those reports will be activated weekly and immediately aft...

The University understands the importance of timely exit counseling. The reporting structure for the January, 2023 determination of students not returning from the holidays did not work properly, and the university has corrected the process. Those reports will be activated weekly and immediately after returning from any campus closure. Tiffany McCann, the Executive Director of Student Financial Services, will verify the Veera reporting structure is in compliance, which should eliminate the chance of a recurring finding.

View Audit 296208

Finding 382620 (2023-001)

Significant Deficiency 2023

Flagler College, Inc.

FL

Student Financial Aid Subrecipient Monitoring Reporting

Student Financial Aid Cluster – Special Tests and Provisions – NSLDS Recommendation: We recommend that the College continue to enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is complet...

Student Financial Aid Cluster – Special Tests and Provisions – NSLDS Recommendation: We recommend that the College continue to enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of the Registrar reports enrollment to NSLDS using the National Student Clearinghouse (NSC). The Registrar’s Office will collaborate with our Information Technology Department to identify and correct all students with erroneous program start dates. As recommended by CLA, the Registrar’s Office is reviewing its process for Clearinghouse submissions in collaboration with the Information Technology Department and Advising Office to ensure that the program-level enrollment effective dates are accurately reflected when a student submits a change of major. Names of the contact persons responsible for corrective action: Sheia Pleasant-Doine and Adam Doine Planned completion date for corrective action plan: May 3, 2024

View Audit 296201

Finding 382607 (2023-001)

Material Weakness 2023

Coos County Airport District

OR

Reporting Internal Control / Segregation of Duties

Coos County Airport District (District) respectfully presents the following corrective action plan in response to deficiencies reported in the District’s June 30, 2023 audit conducted by the independent auditing firm Pauly, Rogers and Co., P.C., Tigard, Oregon. The audit identified both a material w...

Coos County Airport District (District) respectfully presents the following corrective action plan in response to deficiencies reported in the District’s June 30, 2023 audit conducted by the independent auditing firm Pauly, Rogers and Co., P.C., Tigard, Oregon. The audit identified both a material weakness and a significant deficiency: • Material Weakness: During testing of the SEFA, it was observed that the amount originally reported for AIP 44 was materially overstated. We recommend that the SEFA only reflect the current year expenditures. Corrective action plan: The District will only record the amount on the SEFA reflected in the current year expenditures.

View Audit 296187

Finding 382599 (2023-002)

Significant Deficiency 2023

Catholic Charities, Inc.

DE

Cash Management Reporting Significant Deficiency

Major Program: 93.568 - Low Income Home Energy Assistance (Grantor - Department of Health and Social Services) Condition: The 2023 program year heating funds reconciliation report was not completed and submitted to the State of Delaware in a timely manner. Corrective Action Plan: Charities DEAP prog...

Major Program: 93.568 - Low Income Home Energy Assistance (Grantor - Department of Health and Social Services) Condition: The 2023 program year heating funds reconciliation report was not completed and submitted to the State of Delaware in a timely manner. Corrective Action Plan: Charities DEAP program has revised and implemented reconciliation procedures to ensure the program year 2023 heating reconciliation benefit report is completed on April 6, 2024. The final reconciliation report for the 2023 heating benefit refund will be remitted to the State of Delaware Office of Community Services (OCS) in accordance with the established guidelines by April 14, 2024. Process of completion is performed manually: 1. The collection of delivered and non-delivered fuel vendors’ unexpended benefits reports has been obtained from the non-delivered vendors. Completed November 2023. 2. Inter-Agency households’ report of benefits returned to the State of Delaware OCS for the heating season 2023 by the county and by invoice number is in process of being manually completed. 3. The documents noted in procedures 1 and 2 must reconcile with the DEAP billing supervisor report of heating benefits issued - funded and refunded by the vendors. The agency finance unit reporting of paid benefits vs refunded benefits must be compared to the noted reports to verify all report totals equal. 4. The unused benefit report noting the total amount to be returned to the State OCS, is completed once the agency finance unit verification of totals reported in procedures 2 and 3 are accurate for the 2022-2023 heating reconciliation. The program year 2023 reconciliation report will be completed according to OCS’s format and submitted along with the check from the agency for the total amount of the refund. Contact Person Responsible for Corrective Action: Samantha Wallace, Interim Executive Director Anticipated Completion Date of Corrective Action: April 6, 2024

View Audit 296160

Finding 382592 (2023-005)

Material Weakness 2023

Portage Township Schools

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

Finding 2023-005 – Education Stabilization Fund – Reporting Contact Person Responsible for Corrective Action: Linda Williams Contact Phone Number: 219-764-6209 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The PTS Office of Grants and Assessmen...

Finding 2023-005 – Education Stabilization Fund – Reporting Contact Person Responsible for Corrective Action: Linda Williams Contact Phone Number: 219-764-6209 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The PTS Office of Grants and Assessments will collaborate with the PTS Finance Office to establish a system of internal controls and separation of duties to ensure a thorough review prior to the submission of the Annual ESSER Data Report. Anticipated Completion Date: April 2024

View Audit 296149

Finding 382584 (2023-007)

Significant Deficiency 2023

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Beginning January 31, 2024, DDAP started having internal discussions to determine the most effective and efficient methodology to evaluate the internal controls of the SCAs' data being reported to DDAP during the federal grant period and in the PPRs. Steps currently being taken by DDAP include updat...

Beginning January 31, 2024, DDAP started having internal discussions to determine the most effective and efficient methodology to evaluate the internal controls of the SCAs' data being reported to DDAP during the federal grant period and in the PPRs. Steps currently being taken by DDAP include updating the SCAs' monitoring process for the next annual monitoring cycle for FY 2023-24. The goal is to have a sound methodology with formalized policies and procedures in place by April 2024 to ensure the data collected is sampled for accuracy going forward. To ensure accuracy of the information reported by the SCAs, which is included on the PPRs, DDAP will add verification of this data to the current SCA monitoring process. Specifically, the Project Officers who conduct SCA monitoring will: - Add a question to the SCA Pre-Submission packet: ‘How does your SCA track SOR-funded clients in order to accurately report them on the SOR Report?’ The SCA must specifically state how they are accounting for these clients and how they arrive at the data reported to DDAP. If DDAP determines the process is not acceptable, the SCA will be required to revise and resubmit. - During the virtual monitoring call, Project Officers will review the SCA’s written answer to the question, and ensure they have a full understanding of where the SCA keeps data on SOR-funded clients, and how they access this data to complete the SOR reports. - During the onsite monitoring visit, the Project Officers will take the most recently submitted SOR report and ask the SCA staff to duplicate the steps they used to arrive at the reported numbers. * If the SCA is able to demonstrate how clients are tracked and the steps used to determine the reported numbers produce results consistent with what was submitted in the report, the SCA’s submitted data will be considered verified. * If the SCA is unable to demonstrate how clients are tracked, and the steps used to determine the reported numbers do not produce results consistent with what was submitted in the report, the SCA will be required to implement a process by which they can accurately track this data and report client numbers. Any SCA required to implement a new client-tracking system will be required to submit backup documentation with their SOR reports, until such time as they are able to demonstrate to DDAP that they are accurately tracking clients and can demonstrate the steps used to determine their reported numbers. - This review process and results will be added to the Monitoring Report sent to the SCA at the end of the monitoring cycle, to reflect the SCA’s compliance status. Anticipated Completion Date: 09/30/2024 Contact Names: Susan Duff, Chief, Program Monitoring Division; Autumn Croasmun, Project Director for State Opioid Response III Grant; Tia Roebuck, Director, Division of Budget and Procurement

View Audit 296143 Questioned Costs: $1

Finding 382581 (2023-015)

Material Weakness 2023

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Cash Management

Office of Admin.–SSBG: The Bureau of Financial Operations (BFO) will continue conducting during-the-award subrecipient monitoring for the SSBG based on the results of the documented risk assessment. As it relates to the cash management portion of the finding, given the relatively small amount of f...

Office of Admin.–SSBG: The Bureau of Financial Operations (BFO) will continue conducting during-the-award subrecipient monitoring for the SSBG based on the results of the documented risk assessment. As it relates to the cash management portion of the finding, given the relatively small amount of funds involved and the number of counties affected, DHS has determined that it is not economically feasible to change the payment methodology at this time. Anticipated Completion Date: 06/30/2024 Contact Name: Kelly Graham, Director, Div. of Financial Policy and Operations OPD-SSBG: Due to the COVID-19 global pandemic as well as staff turnover and vacancies in OPD, regular monitoring of SSBG grant recipients was not performed on schedule. However, with the hiring of a full complement of staff for the DHS Policy Office, including a Grant Administrator, we are in the process of creating and implementing a robust monitoring plan for all 19 of our grantees for calendar year 2024, including in-person monitoring, desk monitoring, data collection, and analysis. Anticipated Completion Date: 12/31/2024 Contact Name: Jessica Schneider, Exec. Policy Specialist I, Grants

View Audit 296143 Questioned Costs: $1

Finding 382569 (2023-021)

Material Weakness 2023

Commonwealth of Pennsylvania

PA

Reporting Internal Control / Segregation of Duties § 200.303

The Office of Comptroller Operations unit responsible for DHS grant reporting strives for accurate and complete records in respective to all grant reporting responsibilities, and to that end has implemented or is in the process of implementing the follow reporting improvements: - Report submissions:...

The Office of Comptroller Operations unit responsible for DHS grant reporting strives for accurate and complete records in respective to all grant reporting responsibilities, and to that end has implemented or is in the process of implementing the follow reporting improvements: - Report submissions: • Submitted corrected federal unliquidated obligations in the next cumulative quarterly ACF-196R report following the reporting error(s), in accordance with ACF guidance. • Revised the cumulative quarterly ACF-196R for the quarter-ending September 30, 2023, to accurately report the expenditures, in accordance with ACF guidance. - Reporting Preparation Control Improvements: • Improve spreadsheet controls by updating single cell references to “lookups” based on account code, wherever possible. • Include a reconciliation from the grant reports used for the ACF-196R to the reports used for the Commonwealth’s SEFA and/or other similar total federal expenditure reports. As the SEFA reports are designed to include all federal expenditures by ALN, it would assist in identifying if any internal orders were excluded from the grant reporting due to group order attribute system errors. • Update internal procedures for the above changes. - System Controls • As the three internal orders with group attributes system errors were all due to a missing digit in the group number attribute upon setup within the Commonwealth’s enterprise resource planning (ERP) software, work with the Commonwealth’s IT department overseeing the ERP system to determine if a system control can be added to warn and/or require the correct number of characters. Anticipated Completion Date: 06/30/2024 Contact Name: Emily College, Special Assistant

View Audit 296143

Finding 382567 (2023-013)

Significant Deficiency 2023

Commonwealth of Pennsylvania

PA

Reporting Subrecipient Monitoring Significant Deficiency

1. Upon receiving the annual 4th quarter ACF-196R from the Bureau of Financial Management, the Office of Income Maintenance (OIM) Bureau of Policy (BOP) replies with a confirmation receipt and a reminder to send any future revisions of the report with an email priority of important. 2. OIM, BOP up...

1. Upon receiving the annual 4th quarter ACF-196R from the Bureau of Financial Management, the Office of Income Maintenance (OIM) Bureau of Policy (BOP) replies with a confirmation receipt and a reminder to send any future revisions of the report with an email priority of important. 2. OIM, BOP updated the roles in the On-line Data Collections (OLDC) Grant Solutions portal. 3. OIM, BOP set up OLDC Grant Solutions to generate an email notification for any new submissions, revised submissions, or any previous submissions that are withdrawn. 4. OLDC Grant Solutions notifications received between the months of January and March will receive priority to ensure any necessary amendments to the TANF Annual report (ACF-204) are properly submitted by the March 31 deadline. Anticipated Completion Dates: 1 - 11/30/2024; 2, 3 - Completed; 4 - March 2024 Contact Name: Adam Riggs, Director, Division of Family Assistance, OIM, BOP

View Audit 296143

Finding 382537 (2023-003)

Material Weakness 2023

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting

Compliance of the 52 Area Agencies on Aging (AAA) subrecipients is currently being monitored by three Fiscal Representatives using a Phase VIII monitoring tool. As the period of performance of evaluation comes to a close, a new tool will be drafted, taking into consideration the additional need for...

Compliance of the 52 Area Agencies on Aging (AAA) subrecipients is currently being monitored by three Fiscal Representatives using a Phase VIII monitoring tool. As the period of performance of evaluation comes to a close, a new tool will be drafted, taking into consideration the additional need for risk assessments. 1. With the use of a Monitoring log, PDOA plans to perform risk assessments systemically statewide for all Aging Cluster subrecipients. 2. A risk assessment is being developed to evaluate each subrecipient’s risk of noncompliance to proactively address any weaknesses in internal controls over federal programs. - Pointed questions regarding the Organization will be included to gauge management’s ability to follow all terms and conditions of the contract. - General Policies will be reviewed for adherence to all federal and state regulations and competence of personnel administering the programs. - Since multiple federal funding streams are involved, a fiscal component will also be administered to review internal controls for financial issues. 3. As a starting point, PDOA plans to prioritize the larger organizations which typically require more monitoring on an annual basis. 4. Subrecipient monitoring is projected to occur during the fiscal year ended June 30, 2024, for the Aging Cluster subrecipients to ensure timely compliance with all applicable federal regulations. 5. Performance check-ins are launching in April of 2024 as part of a statewide comprehensive monitoring as a new form of regulatory measure. 6. PDOA recognizes time and insufficient staffing as a barrier to achieving the goal of performing a risk assessment for every AAA, but has set an expectation of reaching half at a minimum. 7. Follow-Up procedures resulting from this finding will be reviewed and adjusted as needed to deliver optimal outcomes. Preliminary procedures will be directed to the agency’s audit review committee for resolution of completeness. 8. In the event the audit review committee determines additional steps beyond the monitoring efforts outlined above are insufficient, additional efforts will be communicated to the AAA network. Anticipated Completion Date: 06/30/2024 Contact Name: Jennifer Cave, Fiscal Management Specialist, PDOA Audit Liaison

View Audit 296143 Questioned Costs: $1

Finding 382529 (2023-019)

Significant Deficiency 2023

Commonwealth of Pennsylvania

PA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

L&I: A request has been made to RSA for the correction of the report. A correction will be made by OB-OCO once the report is open. To avoid typographical errors in the future, the CFO and the Division Chief of Budget and Admin will review the report after submission by OB-OCO to ensure the submissio...

L&I: A request has been made to RSA for the correction of the report. A correction will be made by OB-OCO once the report is open. To avoid typographical errors in the future, the CFO and the Division Chief of Budget and Admin will review the report after submission by OB-OCO to ensure the submission is correct. Anticipated Completion Date: 04/15/2024 Contact Name: Zulqarnain Nasir, Chief Financial Officer, OVR, L&I OB-OCO: • General Accounting revised our procedures to include having both the reviewer and preparer match the PDF output to the final Excel spreadsheet. • General Accounting discussed this finding and procedure change with the applicable staff on February 28, 2024 and February 29, 2024. • OVR has requested that the USDE unlock the RSA-17 Report for editing. General Accounting will submit a revised RSA-17 report to USDE once the report is unlocked. Anticipated Completion Date: 04/15/2024 Contact Names: Carson Buck, Commw. Accountant Manager; Kathleen Bolick, Accountant 3

View Audit 296143

Finding 382521 (2023-020)

Significant Deficiency 2023

Commonwealth of Pennsylvania

PA

Subrecipient Monitoring Reporting Significant Deficiency

PEMA Capital Project Reporting: The PEMA Emergency Medical Services Recovery SLFRF Project (87374A) was reported to the federal government with $0 for capital expenditures because all recipients were beneficiaries. The SLFRF federal guidance states the following: 11. Subrecipient Monitoring. SLFRF...

PEMA Capital Project Reporting: The PEMA Emergency Medical Services Recovery SLFRF Project (87374A) was reported to the federal government with $0 for capital expenditures because all recipients were beneficiaries. The SLFRF federal guidance states the following: 11. Subrecipient Monitoring. SLFRF recipients that are pass-through entities as described under 2 CFR 200.1 are required to manage and monitor their subrecipients to ensure compliance with requirements of the SLFRF award pursuant to 2 CFR 200.332 regarding requirements for pass-through entities. First, your organization must clearly identify to the subrecipient: (1) that the award is a subaward of SLFRF funds; (2) any and all compliance requirements for use of SLFRF funds; and (3) any and all reporting requirements for expenditures of SLFRF funds. Recipients should also note that subrecipients do not include individuals and organizations that received SLFRF funds as end users. Such individuals and organizations are beneficiaries and not subject to audit pursuant to the Single Audit Act and 2 C.F.R. Part 200, Subpart F. U.S. Treasury, Compliance and Reporting Guidance, State and Local Fiscal Recovery Funds, Version 5.14, December 14, 2023, Pages 12-13. (This is the current version) Additionally, the U.S. Treasury states in their Quarterly Reporting User Guide Frequently Asked Questions (page 165 of the current edition): 1.20. Who are beneficiaries and are recipients required to report for them? The terms and conditions of federal awards flow down to subawards to subrecipients, requiring subrecipients to comply with all requirements of recipients such as the treatment of eligible uses of funds, procurement, and reporting requirements. Beneficiaries are not subject to the requirements placed on subrecipients in the Uniform Guidance, including audit pursuant to the Single Audit Act and 2 CFR Part 200, Subpart F or subrecipient reporting requirements. OB-GBO interpreted this to mean that reporting was not necessary, but we are seeking clarification from U.S. Treasury. Meanwhile, we will collaborate with PEMA to review grant materials and address capital expenditure questions by July 31, 2024. Capital Project In Excess Of $10M: The Quarter 1 2023 Project and Expenditure Report submitted by the Commonwealth of Pennsylvania did not capture the DCNR State Parks and Outdoor Recreation Grants Program (87360B) as a capital project in excess of $10M. The federal reporting portal inaccurately recorded the submission, and unfortunately, we cannot verify if this was due to a technical issue (there have been several instances we found where information we entered into the portal was reported differently in the U.S. Treasury generated report summary and had to be corrected by the U.S. Treasury after submission) or human error since access to older reports is blocked, nor does the abridged PDF version of the submission from the U.S. Treasury portal contain that specific information. While the error was noted in the Quarter 1 2023 report, it had been corrected in the Quarter 2 report. Currently, there is no further action we can take regarding the Quarter 1 2023 report. We consider this issue resolved. Capital Project Justification Did Not Include All Required Elements: The DCNR State Parks and Outdoor Recreation Grants Program (87360B) has been reported as a capital project. OB-GBO acknowledges that the capital project justification did not include all the required elements below: (i) Describe the harm or need to be addressed; (ii) Explain why a capital expenditure is appropriate; and (iii) Compare the proposed capital expenditure to at least two alternative capital expenditures and demonstrate why the proposed capital expenditure is superior. OB-GBO plans to collaborate with DCNR to ensure future reports include all necessary elements by July 31, 2024. Anticipated Completion Date: 07/31/2024 Contact Names: Michael Wood, Bureau Director, Bureau of Performance, Revenue, and Program Analysis, OB-GBO; Colleen Kling, Division Manager, Division of Programs and Performance, OB-GBO; Samantha Lockhart, Executive Budget Specialist, OB-GBO; Evelyn Madenford, Volunteer Loan Program Administrator, Office of State Fire Commissioner, PEMA; Mark Hansford, Division Manager, Division of Community and Conservation, DCNR

View Audit 296143

Finding 382515 (2023-008)

Significant Deficiency 2023

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties

PDE agrees with the portion of the finding pertaining to the lack of required signature on an expenditure report. To address this error, PDE will retrain staff and update “Tool Tips” in PEARS so that it is clearer for field advisers. PDE disagrees with two of the conditions of the finding, as stat...

PDE agrees with the portion of the finding pertaining to the lack of required signature on an expenditure report. To address this error, PDE will retrain staff and update “Tool Tips” in PEARS so that it is clearer for field advisers. PDE disagrees with two of the conditions of the finding, as stated by the auditors. First, regulation 7 CFR 226.6 (o), cited and summarized by the auditors as requiring PDE to resolve and close reviews within a specific timeline, does not include this requirement in the text. The regulation requires that subrecipients resolve any issues with a timeframe specified in their corrective action. Second, the first bulleted condition, states that “these reviews did not include any complex findings that would have required more time to close.” PDE procedure for closing reviews states that “any exception must be communicated and approved by the Supervisor…” The procedure does not qualify or limit these exceptions to “complex findings.” Accordingly, PDE will continue to follow its procedures as written. Anticipated Completion Date: 06/30/2024 Contact Names: Vonda Ramp, Chief, Div. of Food & Nutr., Bur. of Bdgt. & Fiscal Management; Clayton Carroll, Audit Coord., Bur. of Bdgt. & Fiscal Management

View Audit 296143 Questioned Costs: $1

Finding 382503 (2023-023)

Significant Deficiency 2023

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.1 § 200.332

PDA: For federal programs within the Food Distribution Cluster (ALNs 10.565, 10.568, and 10.569), PDA will put the following steps in place for (1) identifying the federal award information and applicable requirements and (2) evaluating each subrecipient’s risk of noncompliance as Required by the Un...

PDA: For federal programs within the Food Distribution Cluster (ALNs 10.565, 10.568, and 10.569), PDA will put the following steps in place for (1) identifying the federal award information and applicable requirements and (2) evaluating each subrecipient’s risk of noncompliance as Required by the Uniform Grant Guidance. 1) PDA will ensure that FAIN numbers are now included in all new subaward agreements. (For currently existing agreements, PDA will send letters by June 30 to provide the FAIN and reiterate Single Audit requirements.) 2) For those subaward agreements that are permanent and/or cover multiple funding years, PDA will develop procedures to ensure that annual notices are sent to each subrecipient notifying them of the updated FAIN for their agreement and reminding them of the Single Audit requirements that are laid out in the terms of their initial signed agreement. 3) PDA will develop a process to evaluate each subrecipient’s risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring. The evaluation will be based on Key Performance Indicators, such as leadership tenure; prior incidents of food spoilage; or qualitative feedback from clients served. If the evaluation determines that additional monitoring tools beyond the routine performance of on-site reviews of the subrecipient's program operations are necessary, such conditions will be laid out in a separate letter communication to the sub-awardee. Anticipated Completion Date: 06/30/2024 Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance PDOA: PDOA will implement the following steps to evaluate each subrecipient’s risk of noncompliance as required by the uniform grant guidance. 1. Evaluation is ongoing for the impacted Aging Cluster programs. 2. A risk assessment is being developed to evaluate each subrecipient’s risk of noncompliance to proactively address any weaknesses in internal controls over federal programs. - Pointed questions regarding the Organization included to gauge management’s ability to follow all terms and conditions of the contract. - General Policies will be reviewed for adherence to all federal and state regulations and competence of personnel administering the programs. - Since multiple federal funding streams are involved, a fiscal component will also be administered to review internal controls for financial issues. 3. Performance check-ins are launching in April of 2024 as part of a statewide comprehensive monitoring as a new form of regulatory measure. 4. Follow-Up procedures resulting from this finding will be reviewed and adjusted as needed to deliver optimal outcomes. Preliminary procedures will be directed to the agency’s audit review committee for resolution of completeness. 5. In the event the audit review committee determines additional steps beyond the monitoring efforts outlined above are insufficient, additional efforts will be communicated to the AAA network. Anticipated Completion Date: 06/30/2024 Contact Name: Jennifer Cave, Fiscal Management Specialist, PDOA Audit Liaison DOH: DOH plans to develop and implement a robust subrecipient monitoring program which includes establishing a new section within the Budget Office pending enacted budget funds and complement to support the creation of the section. Initiative goals/milestones include: 1. Educate Department: Budget Office is developing a bulletin that will outline the subrecipient monitoring requirements with links to state and federal sources. The bulletin will be shared with all program office staff. The Budget Office will develop the following templates and provide to all program offices: - Determination of vendor status: Subrecipient or Contractor - Risk Assessment Form - Internal Control Self-Assessment for Subrecipient Template - Subrecipient Monitoring Template 2. Implementation of full compliance initiative: Recommendations provided in the assessment will be used to develop and implement comprehensive policies and procedures lead by a new section in the Budget Office. Anticipated Completion Dates: 1 - 03/31/2024; 2 - 03/31/2025 Contact Name: Andrea Race, CFO DHS: Foster Care 1. For the portion of the audit finding that indicates State Agencies Did Not Identify the Federal Award Information and Applicable Requirements at the Time of the Subaward. Beginning state fiscal year 2024-2025, OCYF will begin sending out the required information to the Foster Care non-profit contractor. 2. Separately, OCYF will be developing a risk assessment process for the Foster Care non-profit contractor in state fiscal year 2024-2025. Anticipated Completion Dates: 1 - 06/30/2024; 2 - 06/30/2025 Contact Name: Melissa Erazo, Director, Bureau of Budget and Fiscal Support TANF and SSBG Effective December 31, 2023, DHS’ grant contract with Real Alternatives ended. We have no contract for services with them going forward. Despite repeated attempts and efforts to engage this grantee in ongoing monitoring activities, as well as monitoring after the end of the grant for previous years, they were uncooperative and unresponsive to our requests and therefore regular monitoring was not completed. Due to the Covid-19 global pandemic as well as staff turnover and vacancies in the Office of Policy Development, regular monitoring of SSBG grant recipients was not performed on schedule. However, with the hiring of a full complement of staff for the DHS Policy Office, including a Grant Administrator, we are in the process of creating and implementing a robust monitoring plan for all 19 of our grantees for calendar year 2024, including risk assessments, in person monitoring, desk monitoring, data collection and analysis. Anticipated Completion Date: 12/31/2024 Contact Name: Jessica Schneider, Executive Policy Specialist I, Grants

View Audit 296143 Questioned Costs: $1

Finding 382487 (2023-024)

Material Weakness 2023

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.208 § 200.332 § 200.339 § 200.501 § 200.505

PDA: PDA will be hiring a complement position to develop and maintain an audit tracking report to ensure that all single audits are properly logged and processed. In addition, this position will review the financial information in each audit report to determine if all pass-through funding is properl...

PDA: PDA will be hiring a complement position to develop and maintain an audit tracking report to ensure that all single audits are properly logged and processed. In addition, this position will review the financial information in each audit report to determine if all pass-through funding is properly included and subject to audit. This position will coordinate with the bureaus within PDA to ensure all required follow-up is completed in a timely manner. Anticipated Completion Date: 06/30/2024 Contact Name: Tracee Gotwalt, Audit Coordinator PDOA: The PDOA is looking to improve management decision communications in addition to more thorough evaluations as a new Comprehensive Monitoring Process pilot is starting in April 2024 to address the noncompliance of subrecipient monitoring. This has resulted in management designing control activities to achieve timely submissions in the future by initiating the following: 1. An audit tracking log has been established to track report submissions, document when they were received, initiated, findings requiring follow-up, and subsequent steps to finalize the audit. 2. A separate tracking mechanism is in place to ensure the monitoring of subrecipient activities for compliance with federal statutes, regulations, and the terms and conditions of the Agreement for the 52 Area Agency on Aging subrecipients. 3. PDOA is looking to fill a vacant position with a focus of tracking subrecipient expenditures in the aggregate and tracks Single Audit submissions on a Commonwealth wide basis since the Aging Cluster is material and has material sub-granted expenditures. 4. Since receiving the finding, PDOA has reached out to the resource account where Subrecipient Single Audit reports are received by the Federal Audit Clearinghouse (FAC) to verify all outstanding audit items for PDOA, as action is required within six months of receipt. 5. It is PDOAs impression that having increased oversight of the Schedule of Expenditures of Federal Awards (SEFA) will allow for timely dissemination of Management Decision Letters (MDL) in the six-month timeframe for making a management decision for federal award findings. 6. Additionally, PDOA will confirm a closure letter was sent to the Philadelphia Corporation for Aging documenting PDOA’s management decision regarding federal award findings, as included in their FYE 06/30/2021 Single Audit report. 7. Follow-Up procedures resulting from this finding will be reviewed and adjusted as needed to deliver optimal outcomes. Preliminary procedures will be directed to the agency’s audit review committee for resolution of completeness. 8. In the event the audit review committee determines additional steps beyond the monitoring efforts outlined above are insufficient, additional efforts will be communicated to the AAA network. Anticipated Completion Date: 06/30/2024 Contact Name: Jennifer Cave, Fiscal Management Specialist, PDOA Audit Liaison DOH: DOH’s subrecipient single audit tracking report now includes a mechanism to monitor management decision deadlines related to each entity’s FAC submission date. The process for tracking subrecipient audit reports with findings has been updated to include and highlight subrecipients’ audit reports where DOH is the lead agency for finding resolution or the report contains findings that relate to the Department. Anticipated Completion Date: 03/31/2024 Contact Name: Steven Marsden, Chief, Audit Resolution Section PDE: PDE has implemented weekly, monthly and quarterly checks to ensure that all single audits are properly logged and processed. The clerk typist will conduct a weekly review and provide confirmation to the audit coordinator by signature. Bi-weekly, the clerk typist will follow up on any single audits that remain open. Anticipated Completion Date: Completed Contact Names: Clayton Carroll, Audit Coordinator, Bureau of Budget & Fiscal Management; Jessica Sites, Director, Bureau of Budget & Fiscal Management

View Audit 296143 Questioned Costs: $1

Finding 382486 (2023-004)

Significant Deficiency 2023

Commonwealth of Pennsylvania

PA

Reporting School Nutrition Programs Special Tests & Provisions

PDA strives to maintain accurate and complete records with respect to the receipt, distribution, and inventory of USDA donated foods, including end products processed from donated food. To that end, PDA has already or will put the following steps in place to strengthen procedures for future periods ...

PDA strives to maintain accurate and complete records with respect to the receipt, distribution, and inventory of USDA donated foods, including end products processed from donated food. To that end, PDA has already or will put the following steps in place to strengthen procedures for future periods to ensure any errors are identified and corrected when reconciling the Bureau of Food Assistance’s (BFA’s) Commodity Inventory Report: 1. The finding noted in the audit with regards to the Commodity Inventory Report has been corrected and no known issues remain. 2. BFA will cross-train an additional staff member (the NSLP Specialist) on the process of completing the monthly Commodity Inventory Report. This staff member will then serve as a back-up to the Processing Specialist and will be able to complete a monthly review of the completed Commodity Inventory Report to ensure accuracy. 3. In the event that the numbers in BFA’s Monthly Commodity Inventory Report don’t balance, the Processing Specialist will consult with the Technical Specialist managing PA Meals, who can assist with a technical review of the raw numbers. 4. Sent an email communication to select commodity processors and brokers reiterating the process for submitting Monthly Processing Reports (MPRs) to BFA and reminding them of their responsibility to provide prompt responses should questions arise. Anticipated Completion Dates: 1, 3, 4 - Completed; 2 - 06/30/2024 Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance

View Audit 296143

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