Corrective Action Plans

Finding 537461 (2024-002)

Significant Deficiency 2024

MO

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

Corrective Action Plan 2024-002: The University concurs with the finding. The University has corrected the two Spring 2024 RT24 calculations and initiated additional Pell grant disbursements to the noted students. The University has updated its calculations of the scheduled breaks for the 2024-2025 ...

Corrective Action Plan 2024-002: The University concurs with the finding. The University has corrected the two Spring 2024 RT24 calculations and initiated additional Pell grant disbursements to the noted students. The University has updated its calculations of the scheduled breaks for the 2024-2025 academic year. Completion Date: August 2024 Contact Person: Megan Morton, Director of Financial Services

View Audit 348677

Finding 537460 (2024-003)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

Matching / Level of Effort / Earmarking Student Financial Aid Significant Deficiency § 200.303

Commonwealth: Direct Loan processor will submit monthly reconciliations to Executive Director of Financial Aid or designated campus director for review and approval

View Audit 348667

Finding 537458 (2024-002)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

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

ESU: The University acknowledges this is a repeat finding. While a corrective action plan was implemented in May 2024, the audit sample consisted of students from Fall 2023 and Spring 2024, before the updated procedures were in effect. Since then, the University has enhanced its process for identify...

ESU: The University acknowledges this is a repeat finding. While a corrective action plan was implemented in May 2024, the audit sample consisted of students from Fall 2023 and Spring 2024, before the updated procedures were in effect. Since then, the University has enhanced its process for identifying when a student ceases participation in a course. Faculty are now required to indicate when a student stops attending. If a faculty member and student agree on issuing an incomplete grade, both must sign a document attesting that the incomplete is a valid final grade. This ensures clarity for the Registrar's Office. Registrar staff now update the National Student Clearinghouse promptly once a student’s last date of activity is confirmed, particularly when a student withdraws from all courses. This process supports timely compliance with the 60-day federal reporting requirement. Additionally, the University is reviewing its procedures for reporting program enrollment effective dates to ensure consistency with NSLDS standards. All updates are submitted through the National Student Clearinghouse. IUP: IUP will set guidelines that all degree clearing must be done with the 45 day time line so the students are reported within the 60 days limit Cheyney: Cheyney University of Pennsylvania extracts current enrollment information, including any enrollment status changes for all students from the University system of record based on the schedule timeline provided to NSC. As of Fall 2024, The Registrar’s Office continues to review NSC information following transmission, particularly for effective dates of completely withdrawn students. The NSC reports enrollments to NSLDS for the University. Cheyney University had previously learned that NSLDS did not receive students' enrollment status changes from NSC in a timely manner due the University HCM2 status and timing of students being reported to NSLDS from COD based on Ed’s approval of the University HCM2 submissions Kutztown: We will shorten our process to 2-3 days to compensate from the (up to) 30 day lag between NSC reporting and NSLDS reporting. We will connect with another PASSHE school (not on the findings report) to ascertain how they keep their submissions timely, and learn best practices. We will renew our cooperative efforts with financial aid to ensure both sides of the equation – NSC and NSLDS – are communicating and that both offices are involved in double checking. Commonwealth: The issues with enrollment reporting were one-time issues related to the integration of the three schools and the implementation of and data migration to a new student information system. Issues have been resolved and Commonwealth University is currently reporting on the prescribed schedule Millersville: The Registrar’s Office will evaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure the enrollment effective date reported to NSLDS is aligning with the University’s last date of attendance. Primarily, the frequency of submissions to the NSC.

View Audit 348667

Finding 537456 (2024-001)

Significant Deficiency 2024

State System of Higher Education, Commonwealth of Pennsylvania

PA

Student Financial Aid Reporting Significant Deficiency § 200.303

ESU: The University acknowledges this is a repeat finding. In response, updated policies and procedures were implemented in May 2024. The audit sample included students from Fall 2023 and Spring 2024—periods that predated the implementation of the corrective measures. To improve compliance, the Univ...

ESU: The University acknowledges this is a repeat finding. In response, updated policies and procedures were implemented in May 2024. The audit sample included students from Fall 2023 and Spring 2024—periods that predated the implementation of the corrective measures. To improve compliance, the University has introduced enhanced reporting mechanisms to identify when a student is no longer participating in any enrolled courses during a given semester. Once a determination is made that a student has withdrawn, University Registrar staff manually update the student’s status in the National Student Clearinghouse. This process reduces the delay between a student’s actual withdrawal and the status update reported to NSLDS. These steps are intended to ensure timely and accurate reporting moving forward. IUP: IUP will set guidelines that all degree clearing must be done with the 45 day time line so the students are reported within the 60 days limit. Cheyney:Cheyney University of Pennsylvania utilizes the National Student Clearinghouse as a third-party service provider for enrollment reporting and provides all enrollment data to NSC, believing that enrollment would be reported to NSLDS in compliance with federal regulations; unfortunately, the enrollment data from the NSC roster which is provided to National Student Loan Data Systems (NSLDS), is only matched to students who currently have existing enrollment records in NSLDS. Student enrollment information is provided to NSLDS from Common Originations and Disbursements (COD). Cheyney University is a Heightened Cash Monitoring 2 (HCM2) institution, and students' Title IV aid/ disbursements are reported differently than advance pay institutions. The student records from COD are only provided to NSLDS upon approval of disbursement from Ed after the University HCM2 submissions are approved. As of Fall 2024, Cheyney University has continued to directly report and upload enrollment for all Title IV recipients to NSLDS from the monthly NSC enrollment rosters. Kutztown: We will target shortening our status change reporting process to 2-3 days to compensate from the (up to) 30 day lag between NSC reporting and NSLDS reporting. We will connect with another PASSHE school that was on the findings report for the last period - but not this period - to ascertain how they avoided the repeat, and to learn additional best practices. We will renew our cooperative efforts with financial aid to ensure both sides of the equation – NSC and NSLDS – are communicating and that both offices are involved in double checking Commonwealth: The issues with enrollment reporting were one-time issues related to the integration of the three schools and the implementation of and data migration to a new student information system. Issues have been resolved and Commonwealth University is currently reporting on the prescribed schedule. Millersville: The Registrar’s Office will review its reporting procedures to ensure that students’ statuses are timely reported to NSLDS as required by Federal regulations. Primarily, the frequency of submissions to the NSC.

View Audit 348667

Finding 537453 (2024-003)

Significant Deficiency 2024

Saint Peter's University and Affiliates

NJ

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency

STEM - PODER – Federal Assistance Listing Number 84.031C Recommendation: We recommend the University document and implement policies and procedures that are aligned with Uniform Grant Guidance for suspension and debarment to ensure the University is following requirements. Explanation of disagreemen...

STEM - PODER – Federal Assistance Listing Number 84.031C Recommendation: We recommend the University document and implement policies and procedures that are aligned with Uniform Grant Guidance for suspension and debarment to ensure the University is following requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University is in the process of developing and implementing a formal policy and procedure to verify that a vendor is not debarred or suspended in the System for Award Management (SAM) database. The procedure, which will be in place by the end of FY 2025, will outline roles, responsibilities, and documentation requirements to ensure consistent compliance. Name(s) of the contact person(s) responsible for corrective action: Diane DiStaulo, Director of Accounting Operations, (201) 761-7415 Planned completion date for corrective action plan: by the end of FY2025

View Audit 348651

Finding 537447 (2024-002)

Significant Deficiency 2024

Saint Peter's University and Affiliates

NJ

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 ...

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.007, 84.033, 84.063 and 84.268 Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has developed a policy to identify uncashed Title IV refund checks prior to the 240-day expiration date. The policy includes steps to contact students whose checks did not clear and to return the refunds to the Department within 240 days after the issue date of the check. The procedures will ensure that reviews are completed and returned timely according to applicable regulations. Name(s) of the contact person(s) responsible for corrective action: Lillian Perreira-Talty, Director of Student Accounts (201) 761-6080 Planned completion date for corrective action plan: Completed

View Audit 348651 Questioned Costs: $1

Finding 537443 (2024-001)

Significant Deficiency 2024

Saint Peter's University and Affiliates

NJ

Reporting Student Financial Aid Significant Deficiency

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.063 and 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review ...

Student Financial Aid Cluster – Federal Assistance Listing Numbers 84.063 and 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review its policies and procedures on reporting enrollment information to the NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has updated its policies and procedures for NSLDS submissions via their third-party servicer to ensure relavant information is being captured and reported timely in accordance with applicable regulations. Name(s) of the contact person(s) responsible for corrective action: Kamla Singh-Ramoutar, University Registrar, (201) 761-6051 Planned completion date for corrective action plan: Completed

View Audit 348651

Finding 537413 (2024-028)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Reference Number: 2024-028 Prior Year Finding: 2023-034 Federal Agency: U.S. Department of Homeland Security State Agency: Department of Public Safety Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: FEM...

Reference Number: 2024-028 Prior Year Finding: 2023-034 Federal Agency: U.S. Department of Homeland Security State Agency: Department of Public Safety Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: FEMA-4474-DR-VT (2020), FEMA-4532-DR-VT (2020), FEMA-4621-DR-VT (2021), FEMA-4695-DR-VT (2023), FEMA-4720-DR-VT (2023) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. The Department should continue to improve its procedures and internal controls to ensure that all required subawards and subaward modifications are reported accurately and timely to FSRS no later than the end of the month following the month of issuance in accordance with FFATA reporting requirements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Public Safety will continue implementation of its corrective action plan from the prior year. A new procedure will be developed for a periodic review of FFATA entries to add a control step ensuring that all FFATA entries are timely and accurate. A training will also be delivered to Public Assistance staff to ensure that the FFATA entry process is understood in both FSRS and SAM.gov. These corrective actions will be completed by April 4th, 2025 Scheduled Completion Date of Corrective Action Plan: April 4, 2025 Contacts for Corrective Action Plan: Richard Hallenbeck, Director of Administration/Finance richard.hallenbeck@vermont.gov

View Audit 348596

Finding 537402 (2024-025)

Significant Deficiency 2024

State of Vermont

VT

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2024-025 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023)...

Reference Number: 2024-025 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2024) Compliance Requirement: Special Tests and Provisions – Utilization Control Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls for Medicaid utilization control to ensure that cases are closed timely and that documentation of the results of reviews are maintained and communicated. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Special investigations Unit (SIU) only refers two types of cases to the Medicaid Fraud Residential Abuse Unit (MFRAU), these cases are: Personal Care Attendant (PCA) and provider fraud and abuse. Prior to 2021 most of those cases were kept in paper format. Since then, the SIU has fully transitioned to electronic files only. All PCA cases referred to MFRAU are assigned to the Duty Auditor (DA) of the Special Investigations Unit (SIU). The DA must send the case referral via a form that MFRAU must return with notification of acceptance or declination to investigate the allegation. If the case is accepted, then it remains under “open referred to MFRAU” status in our database and updates must be provided and documented by the DA during our MFRAU/SIU quarterly meetings until SIU receives a closure memo from MFRAU that documents the completion of their review. Additionally, all provider cases remain open with the auditor who investigated and referred the matter until a closing memo is received by the SIU. All documented follow ups are recorded in the case log. Scheduled Completion Date of Corrective Action Plan: This process has been implemented since 2021 for cases generated from that year forward. SIU Procedure Manual has been updated accordingly as of December 31, 2024. Contacts for Corrective Action Plan: Nadeth Fitzgerald, Director – SIU nadeth.fitzgerald@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537401 (2024-024)

Significant Deficiency 2024

State of Vermont

VT

Eligibility Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

Reference Number: 2024-024 Prior Year Finding: 2023-031; 2022-037; 2021-025; 2020-014; 2019-010 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Yea...

Reference Number: 2024-024 Prior Year Finding: 2023-031; 2022-037; 2021-025; 2020-014; 2019-010 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2025) Compliance Requirement: Special Tests and Provisions - Provider Health and Safety Standards Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Agency fully implement its CAP to ensure that documentation is maintained in accordance with program requirements and that all providers are compliant with required health and safety standards. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: All Letters of Good Standing as well as a Standard Operating Procedure to ensure continuation were implemented in April of 2022. Prior to April the process was manual and via telephone or email with the Tax Department. All Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to get a written notification from the Tax Commissioner. As of April 2022 all tax standing reviews are validated with a letter from the Vermont Tax department and documented in the Provider Management Module. Verification with the VT Tax Department of a provider’s tax standing has always occurred; However, the good standing verification was documented in the PMM system and the confirmation of the verification from the VT Tax Department was not consistently maintained in the PMM. Although the Agency has implemented its corrective action plan from a prior year audit, cases will still be identified under this CAP until the provider is due for their 5-year revalidation and successfully revalidates with VT Medicaid. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Deidra Jarvis, Member and Provider Services Supervisor deidra.Jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537400 (2024-023)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Reference Number: 2024-023 Prior Year Finding: 2023-030; 2022-038; 2021-026 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/...

Reference Number: 2024-023 Prior Year Finding: 2023-030; 2022-038; 2021-026 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) 2405VT5MAP (10/1/2023 – 9/30/2024) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency complete implementation of its prior year CAP to ensure that all required subawards and subaward modifications are reported timely to FSRS in accordance with FFATA requirements. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG conducted additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally and reemphasized the FFATA compliance regulations. This ensured the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. The context of the 2024 finding indicates that the departments understood the training materials and complied with the requirements to report. On at least an annual basis, IAG conducts a review of current federal rules and regulations pertaining to FFATA reporting for FSRS to assure the Agency’s procedures are up to-date. Coincidentally, IAG will also select a random sample of subawards and subawards modifications that meet the required threshold for FFATA reporting to ensure they are reported in FSRS system on a complete, accurate and timely basis. Scheduled Completion Date of Corrective Action Plan: March 31, 2025: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537399 (2024-022)

Significant Deficiency 2024

State of Vermont

VT

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2024-022 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023)...

Reference Number: 2024-022 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services (Agency) Federal Program: Medicaid Cluster Assistance Listing Number: 93.775, 93.777, 93.778 Award Number and Year: 2305VT5MAP (10/1/2022 – 9/30/2023) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls for Medicaid eligibility renewals to ensure that benefits for eligible participants are not discontinued. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The error was caused by a caseworker not following the steps within the job aid when processing eligibility for a late renewal form. Coverage closed on 9/30/24 for non-review. The renewal form was received on 10/17/2023 yet, coverage was reinstated for 11/1/2024 instead of 10/1/24. The gap in coverage was corrected on 9/16/2024 and coverage was backdated to 10/1/24. The eligibility unit notified the worker’s supervisor who reviewed the case error with the caseworker. In addition, eligibility staff receive refresher training yearly to review our business processes. The Eligibility Unit will continue to monitor cases through our internal QA process unit and through our off-year reviews conducted by the QC unit. Scheduled Completion Date of Corrective Action Plan: Coverage was corrected on September 16, 2024. Contacts for Corrective Action Plan: Nicole McAllister, Healthcare Assistant Administrator II nicole.mcallister@vermont.gov Sarah York, Healthcare Assistant Administrator I sarah.york@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537387 (2024-021)

Significant Deficiency 2024

State of Vermont

VT

Eligibility Student Financial Aid Subrecipient Monitoring § 200.303

Reference Number: 2024-021 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/202...

Reference Number: 2024-021 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/2023 – 9/30/2026) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls to ensure that it verifies U.S. citizenship for all participants and confirm that only eligible participants receive benefits under the program. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: This finding has been corrected as of January 2024 dating back to October 2023. The State is no longer pooling funding sources which means that we can identify cases by their true funding source. This means that only true CCDF cases will be audited going forward and family service cases (protective service) no longer follow CCDF rules including citizenship and identity. Scheduled Completion Date of Corrective Action Plan: December 31, 2024 Contacts for Corrective Action Plan: Karolyn Long, Operations Director karolyn.long@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537379 (2024-019)

Significant Deficiency 2024

State of Vermont

VT

Matching / Level of Effort / Earmarking Special Tests & Provisions Reporting § 200.303

Reference Number: 2024-019 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number and Year: 2301VTTANF (10/1/2022 – 9/30/2023) 2...

Reference Number: 2024-019 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number and Year: 2301VTTANF (10/1/2022 – 9/30/2023) 2401VTTANF (10/1/2023 – 9/30/2024) Compliance Requirement: Reporting – ACF-199 Special Tests and Provisions – Penalty for Failure to Comply with Work Verification Plan Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that the Agency review and enhance procedures and controls to ensure that it maintains adequate documentation, verification, and internal control procedures to ensure the accuracy of work participation rates reported in the ACF-199 reports. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: For the data system programming error finding, the Department removed the hard coding in the programming that limited participant hours to 40. This was completed as soon as the error was identified and our regional team approved the proposed corrective action. For the individual instances where the reported work participation rates reported on the ACF-199 report did not agree with supporting documentation and that supporting documentation contained errors or was incomplete, the Department will do the following: • Highlight each of the individual types of errors in our weekly newsletter that goes out to all staff and describe the correct action that should have been taken in documentation. • Have members of Reach Up Central Office (RUCO) team attend the Senior Benefits Program Specialist Sr. BPS) meeting to review the individual types of errors and describe the correct action that should have been taken. Sr. BPS are responsible for the direct training of district Benefits Program Specialists (BPS) that process eligibility. Following their meeting they will return to their district offices and provide an overview to the district eligibility staff. • RUCO will hold a virtual office hours session for eligibility staff to attend focused on the individual types of errors and the correct action that should have been taken. Scheduled Completion Date of Corrective Action Plan: • Data system programming error was corrected in October 2024. • Newsletter highlights will be shared with staff by January 31, 2025. • Sr BPS meeting will be attended by February 28, 2025. • Virtual office hours will be held by March 31, 2025. Contacts for Corrective Action Plan: Chris Dorer, Reach Up Assistant Administrator christine.dorer@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537373 (2024-016)

Significant Deficiency 2024

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Reference Number: 2024-016 Prior Year Finding: 2023-018; 2022-029; 2021-018 Federal Agency: U.S. Department of Education State Agency: Agency of Education Federal Program: COVID-19 – Governor’s Emergency Education Relief Fund COVID-19 – Elementary and Secondary School Emergency Relief Fund (ESSER) C...

Reference Number: 2024-016 Prior Year Finding: 2023-018; 2022-029; 2021-018 Federal Agency: U.S. Department of Education State Agency: Agency of Education Federal Program: COVID-19 – Governor’s Emergency Education Relief Fund COVID-19 – Elementary and Secondary School Emergency Relief Fund (ESSER) COVID-19 - Coronavirus Response and Relief Supplemental Appropriations Act, 2021 – Emergency Assistance to Non-Public Schools (CRRSA EANS) COVID-19 – American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP ESSER) COVID-19 - American Rescue Plan – Elementary and Secondary School Emergency Relief –Homeless Children and Youth Assistance Listing Number: 84.425C, 84.425D, 84.425R, 84.425U, 84.425W Award Number and Year: S425C210009 (1/8/2021 – 9/30/2022) S425D210011 (1/5/2021 – 9/30/2022) S425R210033 (2/23/2021 – 9/30/2022) S425U210011 (3/24/2021 – 9/30/2023) S425W210047 (4/23/2021 – 9/30/2023) Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Agency complete implementation of its corrective action plan from the prior audit. It should review and enhance internal controls and procedures to ensure that all required subawards and subaward amendments are reported timely and accurately to FSRS no later than the end of the month following the month of issuance. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Agency implemented a reconciliation process in March of 2023 that allows us to ensure our grant ledgers agree with what is entered into FFATA. The Agency will increase the number of reconciliations per year to quarterly. The Agency continues to work toward our preferred solution to address the accuracy and timeliness of our entries into the FFATA system by creating an upload file of the data from our grants management system. Scheduled Completion Date of Corrective Action Plan: July 1, 2025 Position Responsible for Implementation of Corrective Action Sean Cousino, Interim CFO sean.couisno@vermont.gov

View Audit 348596

Finding 537368 (2024-013)

Significant Deficiency 2024

State of Vermont

VT

Questioned Costs Cash Management Matching / Level of Effort / Earmarking § 200.303 § 200.343

Reference Number: 2024-013 Prior Year Finding: No Federal Agency: U.S. Department of Transportation State Agency: Agency of Transportation Federal Program: Federal Transit Cluster Assistance Listing Number: 20.500, 20.507, 20.526 Award Number and Year: VT-04-0021-01 (3/14/2013 – 6/30/2016) Complianc...

Reference Number: 2024-013 Prior Year Finding: No Federal Agency: U.S. Department of Transportation State Agency: Agency of Transportation Federal Program: Federal Transit Cluster Assistance Listing Number: 20.500, 20.507, 20.526 Award Number and Year: VT-04-0021-01 (3/14/2013 – 6/30/2016) Compliance Requirement: Cash Management, Period of Performance Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that VTrans review and enhance grant closeout procedures and internal controls to ensure that grants are closed out timely. We further recommend that VTrans review and enhance procedures and internal controls over cash management to ensure that cash draws are performed only against grants for which the period of performance has not expired. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The following factors contributed to the noncompliance: VTrans experienced staff turnover, at which point close out processes were missed in 2016. This resulted in a grant remaining with an open status in the TrAMS system well beyond the period of performance. During the 2024 review by program staff, a drawdown was inadvertently processed for this grant with the expired period of performance. At the time, VTrans lacked a formal, documented grant closeout process for FTA grants in the TrAMS system. Additionally, there was a breakdown in communication between the Accounts Receivable (AR) team and the Public Transit Program team regarding period of performance eligibility prior to processing the draw. VTrans has taken the following steps to strengthen internal controls and prevent recurrence of this issue: 1. Formalized Closeout Procedures: VTrans has implemented a structured grant closeout process for the AOT Public Transit Program that clearly defines responsibilities, timelines, and verification steps to ensure all federal awards are closed timely and in compliance with FTA requirements. This process assigns specific tasks to designated staff members and ensures that no drawdowns occur after the period of performance has ended. 2. Annual Period of Performance Review: VTrans has established and documented an annual review process for FTA grant periods of performance. This review has been formally integrated into the Agency’s Public Transit cash management procedures, ensuring that grant end dates are proactively monitored, and necessary extensions or closeouts are addressed before expiration. 3. Enhanced Communication and Documentation: VTrans has updated the internal Excel file used to facilitate communication between the Public Transit Program team and the AR team. The file now includes a designated column for period of performance, ensuring that all drawdowns are reviewed for eligibility before processing. This is also addressed in an update to the Agency’s Public Transit cash management procedure memo. VTrans will coordinate with FTA to determine the appropriate resolution for these funds. Any necessary repayment or adjustments will be completed in accordance with FTA guidance. At this time, FTA has not requested the funds be returned. Scheduled Completion Date of Correction Action Plan: All corrective actions will be implemented as of March 1, 2025. Contacts for Corrective Action Plan: Ross MacDonald, Public Transit Director ross.macdonald@vermont.gov

View Audit 348596 Questioned Costs: $1

Finding 537367 (2024-012)

Significant Deficiency 2024

State of Vermont

VT

Matching / Level of Effort / Earmarking Special Tests & Provisions Significant Deficiency § 200.303

Reference Number: 2024-012 Prior Year Finding: No Federal Agency: U.S. Department of Transportation State Agency: Agency of Transportation Federal Program: Highway Planning and Construction Assistance Listing Number: 20.205 Award Number and Year: FFY2023 – FFY2024 Compliance Requirement: Special Tes...

Reference Number: 2024-012 Prior Year Finding: No Federal Agency: U.S. Department of Transportation State Agency: Agency of Transportation Federal Program: Highway Planning and Construction Assistance Listing Number: 20.205 Award Number and Year: FFY2023 – FFY2024 Compliance Requirement: Special Tests and Provisions – Wage Rate Requirements Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: VTrans should review and enhance procedures and internal controls to ensure that it obtains weekly certified payrolls from all contractors. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Daily Work Reports (DWRs) submitted by the contractor concluded the outstanding punchlist items in June 2023, and in September 2023 a subcontractor submitted a DWR to AOT. The project went through Completion and Acceptance (C&A) in December 2023. The C&A process required confirmation that payrolls were received but did not include a final complete-verification step before project closeout. As a result, missing payroll certifications went unnoticed. Additionally, the Civil Rights team was unaware of the subcontractor’s work report since their review is triggered by certified payroll submissions, not DWRs. VTrans is updating the C&A checklist to require final confirmation that all certified payrolls have been received before project closeout, with coordination from the Civil Rights team if any are missing. This checklist is to be verified by both the Resident Engineer and the Regional Engineer. To further strengthen compliance, VTrans Construction will focus on education, and revise pre-construction meeting templates to emphasize that federal wage reporting requirements apply to all work on a project. Additionally, VTrans Civil Rights will reinforce these requirements in annual contractor training to ensure Prime and Subcontractors fully understand their payroll reporting responsibilities. VTrans will also remain cognizant of projects and DWRs submitted by new subcontractors and actively work to educate contractors at this point to prevent future payroll omissions. Scheduled Completion Date of Corrective Action Plan: All corrective actions will be implemented as of April 1, 2025. Contacts for Corrective Action Plan: Douglas Bonneau, VTrans Construction Engineer douglas.bonneau@vermont.gov

View Audit 348596

Finding 537362 (2024-010)

Significant Deficiency 2024

State of Vermont

VT

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303 § 200.308 § 200.309 § 200.403

Reference Number: 2024-010 Prior Year Finding: 2023-008; 2022-017 Federal Agency: U.S. Department of Labor State Agency: Vermont Department of Labor Federal Program: Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: Admin 24A55UI000063 (10/1/2023-12/31/2026), DUA 23A6...

Reference Number: 2024-010 Prior Year Finding: 2023-008; 2022-017 Federal Agency: U.S. Department of Labor State Agency: Vermont Department of Labor Federal Program: Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: Admin 24A55UI000063 (10/1/2023-12/31/2026), DUA 23A60UD000013 (7/14/2023 - 7/14/2026) Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the Department review and enhance its procedures and controls to ensure that prior to charging costs to the program, they are incurred within an award’s allowable period of performance. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Department will review its procedures and internal controls and update as necessary to ensure that expenditures are incurred within the allowable period of performance for respective awards. It should be noted that during the period of performance for which this audit was conducted there were a large number of personnel changes and shifts. The position that was responsible for the majority of these duties retired in January 2024. We proactively hired for her replacement a year before she retired. Over the course of the year our replacement took over more and more duties. In the process of this replacement, we have completed a tremendous amount of evaluation of our assigned duties, processes, workflow, training, and documentation. Not only in this role, but we are also undergoing a division and business unit wide analysis of our internal controls and workflow. It should also be noted that the UI admin funds are considered ‘formula funds’ from the US DOL. We are expected to run this program year-round with no gaps in service or performance. The funding that we receive from US DOL is based on an antiquated formula that breaks down the amount that is budgeted by Congress between 52 state and territories. We generally do not receive enough funding for the entire year. Also, with the recent trend of Congress to utilize the tool of the Continuing Resolution our funding is often ambiguous until most of the program year is over. We have at times seen our funding cut once a budget had been passed by Congress even though there was only about 3 months left in the program year. We are still expected to run this program and ‘find other sources of funding’. This does make the adherence to the period of performance challenging. However, as we evaluate our internal controls and procedures over the coming months, we will make note of every opportunity to strengthen this function to ensure that all charges applied to program funds are relevant, within the period of performance of the award, and are correctly reviewed and signed. Scheduled Completion Date of Corrective Action Plan: April 1, 2025 Contacts for Corrective Action Plan: Chad Wawrzyniak, Financial Director II chad.wawrzyniak@vermont.gov

View Audit 348596 Questioned Costs: $1

Finding 537359 (2024-007)

Significant Deficiency 2024

State of Vermont

VT

Allowable Costs / Cost Principles Subrecipient Monitoring Period of Performance § 200.303 § 200.308 § 200.309 § 200.403

Reference Number: 2024-007 Prior Year Finding: No Federal Agency: U.S. Department of Defense State Agency: Vermont State Military Department Federal Program: National Guard Military Operations and Maintenance (O&M) Projects Assistance Listing Number: 12.401 Award Number and Period: W912LN2421001 (10...

Reference Number: 2024-007 Prior Year Finding: No Federal Agency: U.S. Department of Defense State Agency: Vermont State Military Department Federal Program: National Guard Military Operations and Maintenance (O&M) Projects Assistance Listing Number: 12.401 Award Number and Period: W912LN2421001 (10/1/2023 – 9/20/2024) Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: The Department should review and enhance its procedures and internal controls to ensure that it charges expenditures to the program that are incurred within an award’s allowable period of performance. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Department agrees with this finding and will implement the following: • Update Accounts Payable Standard Operating Procedures to include instructions for determining the appropriate Federal Fiscal year for coding and paying vendor invoices. • Distribute updated procedures and train staff to ensure understanding of Period of Performance reporting requirements. • Update Vision query to include the Invoice Date field. Current reports used for preparing the SF-270 only include the Vision transaction date, therefore the preparer and reviewer are not able to determine the performance dates of individual transactions based on this report alone and rely on proper coding of the Class field during voucher entry. Adding the Invoice Date to the report will improve the department’s ability to QC the SF-270 for period of performance discrepancies prior to submission for reimbursement. • The Financial Director will perform quarterly audits of this Vision report to identify any improper reporting. Any errors identified will be corrected with a journal voucher and subsequently corrected on the next SF-270. Scheduled Completion Date of Corrective Action Plan: April 15, 2025 Contacts for Corrective Action Plan: Kim Fedele, Financial Director kimberly.fedele@vermont.gov

View Audit 348596

Finding 537342 (2024-026)

Significant Deficiency 2024

State of Vermont

VT

Questioned Costs Cash Management Reporting § 200.303 § 200.514

Reference Number: 2024-026 Prior Year Finding: 2023-023 Federal Agency: U.S. Department of Agriculture U.S. Department of Health and Human Services State Agency: Department of Finance and Management Federal Program: SNAP Cluster Temporary Assistance for Needy Families CCDF Cluster Assistance Listing...

Reference Number: 2024-026 Prior Year Finding: 2023-023 Federal Agency: U.S. Department of Agriculture U.S. Department of Health and Human Services State Agency: Department of Finance and Management Federal Program: SNAP Cluster Temporary Assistance for Needy Families CCDF Cluster Assistance Listing Number: 10.551, 10.561, 93.558, 93.575, 93.596 Award Number and Year: 4VT400406 (10/1/2022 – 9/30/2023) 4VT402513 (10/1/2023 – 9/30/2024) 2301VTTANF (10/1/2022 – 9/30/2023) 2401VTTANF (10/1/2023 – 9/30/2024) 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/2023 – 9/30/2026) Compliance Requirement: Cash Management Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that Finance review and enhance its internal controls and procedures over the CMIA Annual Report to ensure that it verifies the correct interest rate is applied and that State and Federal interest liabilities are properly calculated in accordance with 2 CFR section 200.514. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The current available rate at the time of calculation, review, entry, and moving to draft were all accurate to what U.S. Treasury had available at the time. The rate was updated on December 3rd, after our submissions had already been locked via the draft process in the CMIAS portal done on November, 26th. The process was not fully submitted due to issues with the CMIAS portal not allowing us to submit which has been extensively documented via multiple email chains with U.S. Treasury CMIA over the past two years. Finance and Management will take a screenshot of the CMIA interest rate page dated on the review date of the CMIA Annual Report submissions from departments to ensure that we maintain the historical rate posted to the U.S. Treasury CMIA page at the time of review. Additionally, AHS will take their own screenshots of the CMIA Interest Rate page from U.S. Treasury website on the date of their Annual Report Summary submissions for record and to show that the rate from this time was checked and applied to the current year’s program. If during the review, there is any discrepancy between the review screen of the rates and the calculations screenshot of the rates; the calculation spreadsheets will be kicked back to AHS to be updated. Scheduled Completion Date of Corrective Action Plan: November 30, 2025 Contacts for Corrective Action Plan: Jordan Black-Deegan, Statewide Grants Administrator jordan.black-deegan@vermont.gov Sarena Boland, Financial Manager III sarena.boland@vermont.gov

View Audit 348596 Questioned Costs: $1

Finding 537340 (2024-005)

Significant Deficiency 2024

State of Vermont

VT

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2024-005 Prior Year Finding: No Federal Agency: U.S. Department of Agriculture State Agency: Agency of Human Services Federal Program: SNAP Cluster Assistance Listing Number: 10.551, 10.561 Award Number and Year: 4VT400406 (10/1/2022 – 9/30/2023) 4VT402513 (10/1/2023 – 9/30/2024) C...

Reference Number: 2024-005 Prior Year Finding: No Federal Agency: U.S. Department of Agriculture State Agency: Agency of Human Services Federal Program: SNAP Cluster Assistance Listing Number: 10.551, 10.561 Award Number and Year: 4VT400406 (10/1/2022 – 9/30/2023) 4VT402513 (10/1/2023 – 9/30/2024) Compliance Requirement: Special Tests and Provisions – EBT Card Security Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend that the Agency review and enhance internal controls to ensure that it maintains documentation of the daily/weekly reconciliation of destroyed EBT cards. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: Cards were automatically printing at 1:00 AM which presented many opportunities for errors. The printers can only hold 100 cards in their hoppers and only print on one printer at a time. If there were more than 100 cards to be printed the printer(s) would error out and subsequently drop cards from the print file and/or print duplicates when the errors were corrected once someone was in the office. We have now updated the print jobs to print at 9:00 AM when a trained EBT staff member is there to monitor the printing. Additionally, we have a system in place to rotate printing on the 3 printers monthly to spread the wear and tear evenly. Increases to opened card inventory, decreases in the opened card inventory due to printing, and decreases in the opened card inventory due to shredded cards are included on the daily “Card Count” Excel that is then converted to a PDF for signatures through DocuSign. This daily “Card Count” Excel is updated and verified by EBT personnel to ensure that the remaining opened card inventory is reflective of what was added to the opened card inventory, what was printed, and what was shredded. Printed card counts on this “Card Count” Excel and PDF will be reflective of the daily “EBT Printing Reports” that are auto generated and e-mailed to the EBT staff. When there are excessive shredded cards (more than 5) EBT personnel will create a detailed e-mail to verify the day’s events with IT personnel. Once verified by the IT personnel, the e-mail will be a part of the DocuSign packet for the “Card Count” PDF to explain and backup the events from that particular day. The “Card Count” Excel and PDF is produced by the EBT staff person in the office to physically oversee that day’s printing. EBT staff rotate days that they are in the office; meaning that the EBT Financial Manager and the Financial Director of Operations verify that the rolling count is correct each week on Thursday’s and Wednesday’s (respectively) as they are in the office to process the printed cards. Scheduled Completion Date of Corrective Action Plan: EBT personnel have implemented the above e-mail attachment to the “Card Count” PDF solution as of November 2024. Contacts for Corrective Action Plan: Katherine Lettieri, Financial Manager III katherine.lettieri@vermont.gov Kristina Roy, Admin Services Coordinator I kristina.roy@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 348596

Finding 537307 (2024-002)

Significant Deficiency 2024

Municipality of Moca

PR

Subrecipient Monitoring Reporting Significant Deficiency § 200.328

Finding 2024-002: Compliance requirement: Reporting-Coronavirus State and Local Fiscal Recovery Reportable Condition: See Condition 2024-002 Recommendation ...

Finding 2024-002: Compliance requirement: Reporting-Coronavirus State and Local Fiscal Recovery Reportable Condition: See Condition 2024-002 Recommendation The Municipality should maintain the schedule of the due dates or the reuired rports of each federal program to comply with the required submissions to the federal awarding agencies. Also, they had to submi the quaterly report to comply with the requiremnts. Action Taken Due to the shift from annual to quaterly reporting, the Municipality initially missed a quaterly report deadline because of unfamiliarity with the new schedule. however, since then , we have consistently met all the subsequent quaterly deadlines. we will continue to carefully monitor and verifiy all reporting deadlines to guarantee accurate and timely submissions moving foward.

View Audit 348562

Finding 537266 (2024-002)

Significant Deficiency 2024

Phoenix Indian Center

AZ

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.510

Corrective Action Plan: Several steps have been taken to address the need for timely and accurate reporting. The steps taken and listed below will allow management to properly administer grants and file audit and data collection timely in the future. Turnover of finance staff occurred. Management ac...

Corrective Action Plan: Several steps have been taken to address the need for timely and accurate reporting. The steps taken and listed below will allow management to properly administer grants and file audit and data collection timely in the future. Turnover of finance staff occurred. Management acquired the services of an outside firm to address the deficiencies in the records and to correct and establish a system in order to prevent further occurrences of late reconciliations and untimely reporting. Management has restructuring the finance department with two positions, hiring a Director of Finance and Grants & Contracts Analyst. Additional steps implemented and processes improved in order to establish a system of recording and reporting all financial events: • Payroll entry is streamlined including contemporaneous entry. • Credit cards – Reporting and recording is established in a file so that purchases are logged at the initialization of each purchase. • Reconciliation of all balance sheet accounts are maintained on a current month basis. • A checklist is established for monthly steps. This checklist is maintained by Finance and forwarded to the CEO along with the monthly financial reports. • A thorough review of separation of duties for internal controls was conducted. Implementation is an ongoing process as is analyzing improvements. Persons Responsible: Jolyana Begay-Kroupa, CEO Katherine Gray, Finance Director Estimated Completion Date: June 30, 2025

View Audit 348497

Finding 537263 (2024-003)

Significant Deficiency 2024

Project Quest

OR

Reporting Significant Deficiency

Finding # 2024-003 Type: Significant deficiency over reporting A.L. Number: 21.027 Department of U.S. Treasury Significant Deficiency Reports submitted to funding agencies did not have documented review and approval. Corrective Action: The Organization agrees with the auditor’s recommendation. A...

Finding # 2024-003 Type: Significant deficiency over reporting A.L. Number: 21.027 Department of U.S. Treasury Significant Deficiency Reports submitted to funding agencies did not have documented review and approval. Corrective Action: The Organization agrees with the auditor’s recommendation. At the time of this audit’s publishing, the Organization has implemented additional procedures and controls to document review and approval of reports. Anticipated Completion Date March 2025

View Audit 348495

Finding 537253 (2024-002)

Significant Deficiency 2024

Youth Shelters and Family Services, Inc.

NM

Reporting Subrecipient Monitoring Significant Deficiency § 200.510

Views Of Responsible Officials and Corrective Action Plan Response: Youth Shelters and Family Services, Inc. (YSFS) acknowledges the finding and agrees that improvements are needed in preparing the Schedule of Expenditures of Federal Awards (SEFA). YSFS is committed to ensuring compliance with 2 C...

Views Of Responsible Officials and Corrective Action Plan Response: Youth Shelters and Family Services, Inc. (YSFS) acknowledges the finding and agrees that improvements are needed in preparing the Schedule of Expenditures of Federal Awards (SEFA). YSFS is committed to ensuring compliance with 2 CFR 200.510(b) and will take the necessary steps to enhance the accuracy and timeliness of SEFA preparation. Corrective Action Plan: To address the identified deficiencies, YSFS will develop processes to aid in the implementation of the following corrective actions: 1. Establish a Formal SEFA Preparation Process: • Develop and implement a standardized SEFA preparation procedure, including all required elements (a federal portion of expenditures, grant name, grantor name, Assistance Listing number, and pass-through entity information). • Assign clear responsibilities for SEFA preparation and review to designated finance personnel. • SEFA will be prepared quarterly, rather than waiting until year-end, to allow for ongoing review and corrections. 2. Improve Internal Controls Over SEFA Preparation: • Implement a reconciliation process to compare SEFA expenditures with the federal revenues and expenditures. • Review and update QuickBooks job categories regularly to ensure proper coding of federal expenditures. • Establish a dual-review process where a second finance team member or external consultant reviews SEFA for accuracy before submission. 3. Training and Capacity Building: • Provide training to finance staff on Uniform Guidance requirements for SEFA preparation. • Ensure staff are familiar with federal grant compliance requirements and reporting obligations. 4. Enhance Monitoring and Accountability: • Set internal deadlines for SEFA preparation to prevent delays. • Conduct periodic internal reviews of federal grant expenditures to ensure compliance and accuracy. • Management oversight of SEFA preparation is required to ensure completeness and correctness. Finding resolved timeline: YSFS aims to develop a process to implement these corrective actions and have an accurate, timely SEFA process by June 30, 2025, to ensure compliance with federal regulations in the upcoming fiscal year. Designation of employee position responsible for meeting this deadline: Heather Hoffman, Julie Weigand, and an external consultant will oversee and ensure this corrective action plan's development and successful implementation.

View Audit 348481

Corrective Action Plans

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