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2023-008 – Procurement, Above Simple Acquisition (Significant Deficiency in Internal Controls over Compliance) Recommendation: We recommend the College strengthen controls to ensure purchasing policies and procedures are being followed and train staff in the purchasing department to comply with all...
2023-008 – Procurement, Above Simple Acquisition (Significant Deficiency in Internal Controls over Compliance) Recommendation: We recommend the College strengthen controls to ensure purchasing policies and procedures are being followed and train staff in the purchasing department to comply with all relevant federal procurement requirements. Action Taken: The 2022-2023 fiscal year was entirely encompassed by the separation Memorandum of Understanding (MOU) of March 2022 and then the final release settlement in December 2023. It is important to note that Southeast New Mexico College was a newly established independent community college, having formally separated from New Mexico State University (NMSU) as of April 2022. During this transition period, many administrative processes, including federal grant compliance procedures, were in the process of being developed, transitioned, and implemented independently from NMSU systems. As a result, certain policies, procedures, and documentation processes were not yet fully established or operational at the time of the audit. During the audit period, the College operated under procurement policies and procedures inherited from New Mexico State University (NMSU), as the College had recently separated from NMSU. The procedures were followed in good faith. Two College employees successfully completed Certified Procurement Officer (CPO) training in July 2021 and were recertified in March 2024. Another employee became certified in February 2024, and the College is having two additional employees participate in fiscal year 2025. This training demonstrates the College’s commitment to compliance and proper procurement practices. Unfortunately, due to the untimely receipt of the completed audit report, the College did not have the opportunity to review and begin addressing several of the findings until well after the end of the audit period. While the College is committed to corrective action, the delayed delivery of the audit limited the ability to implement corrective measures earlier. The College is working proactively to ensure that these issues are resolved going forward. Corrective Action Taken / Planned: • Policy and Procedure Revision o The institution will revise its procurement policies and procedures to explicitly address purchases exceeding the Simplified Acquisition Threshold, incorporating:  Public solicitation and competitive bidding requirements  Cost or price analysis requirements per 2 CFR §200.324  Documentation of bid evaluations, vendor selection, and contract award  Use of federally compliant contract clauses (per 200.327 and Appendix II). • Training o Procurement, finance, and grant management staff will be trained on updated procedures, including:  Competitive procurement processes  Cost/price analysis methods  Documentation requirements • Procurement Checklist: o A standardized procurement checklist will be developed and required for all procurements above the Simplified Acquisition Threshold to ensure all federal steps are documented and reviewed. • Pre-Award Review Process o For all purchases above the Simplified Acquisition Threshold, the institution will implement a review and approval process involving procurement leadership and the grants compliance office before contract award. • Monitoring: o Annual internal monitoring will be conducted by the Procurement Office or Grants Compliance Office to ensure ongoing compliance with federal procurement requirements. Due Date of Completion: August 31, 2025 Responsible Official: Carolyn Kasdorf, Vice President for Business and Finance (or appropriate official), Karla Volpi, Dean of Business and Finance, Rebecca Silva, Director of Finance, Lisa Ryan, Restricted Funds Manager
2023-005 – Inadequate Policies and Procedures (Significant Deficiency in Internal Controls over Compliance) Recommendation: We recommend the College establish the required written procedures for federal monies and have them available to all personnel who work with federal programs. Action Taken: T...
2023-005 – Inadequate Policies and Procedures (Significant Deficiency in Internal Controls over Compliance) Recommendation: We recommend the College establish the required written procedures for federal monies and have them available to all personnel who work with federal programs. Action Taken: The 2022-2023 fiscal year was entirely encompassed by the separation Memorandum of Understanding (MOU) of March 2022 and then the final release settlement in December 2023. It is important to note that Southeast New Mexico College was a newly established independent community college, having formally separated from New Mexico State University (NMSU) as of April 2022. During this transition period, many administrative processes, including federal grant compliance procedures, were in the process of being developed, transitioned, and implemented independently from NMSU systems. As a result, certain policies, procedures, and documentation processes were not yet fully established or operational at the time of the audit. Unfortunately, due to the untimely receipt of the completed audit report, the College did not have the opportunity to review and begin addressing several of the findings until well after the end of the audit period. While the College is committed to corrective action, the delayed delivery of the audit limited the ability to implement corrective measures earlier. The College is working proactively to ensure that these issues are resolved going forward. Corrective Action Taken / Planned: • Policy Development o The institution will develop comprehensive written policies and procedures to address compliance requirements related to 2 CFR 200, Subparts D and E of the Uniform Guidance and approved by institutional leadership by July 31, 2025. • Policy Review and Approval o Draft policies will be reviewed by VP of Business and Finance and approved by institutional leadership by August 31, 2025. • Training o Relevant personnel will be trained on the new policies and procedures to ensure consistent understanding and compliance. • Implementation o The institution will fully implement the new procedures by August 31, 2025, and will ensure all departments involved with federal awards are following them. • Ongoing Review: o Policies and procedures will be reviewed annually, and updates will be made as necessary to ensure continued compliance with federal regulations. Due Date of Completion: August 31, 2025 Responsible Official: Carolyn Kasdorf, Vice President for Business and Finance (or appropriate official), Karla Volpi, Dean of Business and Finance, Rebecca Silva, Director of Finance, Lisa Ryan, Restricted Funds Manager
Finding 2023-009 – Completion and Submission of Annual Single Audit - Significant Deficiency/Noncompliance Condition/Context: The County's Single Audit and reporting package was delayed for the year-ended December 31, 2022, as a result of turnover within its Budget and Finance Office, beyond the n...
Finding 2023-009 – Completion and Submission of Annual Single Audit - Significant Deficiency/Noncompliance Condition/Context: The County's Single Audit and reporting package was delayed for the year-ended December 31, 2022, as a result of turnover within its Budget and Finance Office, beyond the nine month due date. Corrective Action: The Controller’s office has new procedures in place to help facilitate the year end closing process so the audit can be completed in a timely manner. Responsible for Implementing Corrective Action: Controller’s Office Anticipated Completion Date: We anticipate this to be completed in coordination with the 2026 audit.
Finding 575815 (2023-001)
Significant Deficiency 2023
Yeshiva Darkei EmunahYeshiva Darkei Emunah respectfully submits the following corrective action plan for the year ended December 31, 2023. Hirsch | Dinter & Co. CPAs: 21 Remsen Avenue, Suite #302, Monsey, New York 10952 Audit Period: January 01, 2023 - December 31, 2023 The finding from the Dece...
Yeshiva Darkei EmunahYeshiva Darkei Emunah respectfully submits the following corrective action plan for the year ended December 31, 2023. Hirsch | Dinter & Co. CPAs: 21 Remsen Avenue, Suite #302, Monsey, New York 10952 Audit Period: January 01, 2023 - December 31, 2023 The finding from the December 31, 2023 schedule of prior audit findings is discussed below. Finding 2023-001: Federal Awards Program Audit U.S. Department of Agriculture Child Nutrition Cluster Programs Deficiency: See Finding 2023-001 Recommendation: The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end, and the auditors should put this engagement on their calendar well in advance of the due date. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. The Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight. Anticipated Completion Date: 09/30/2026 Actions Taken: The Organization has begun implementing the above-mentioned recommendations. The Organization will ensure that it has a working compliance calendar to assist in meeting the reporting deadline. Additionally, the Organization has engaged the audit firm for their upcoming fiscal year-end, and the audit firm has put it on its calendar to begin the audit process well in advance. The Organization’s board of directors has agreed to oversee the auditing and reporting processes to a greater extent. With these actions, the Organization expects to comply with the Uniform Guidance for single audits deadline for the fiscal year end December 31, 2025. Mr. Joel Stein, executive director, has been designated to monitor the plan of corrective action for this finding. He can be reached at 845-356-2761. Contact Person Responsible for Corrective Action: Joel Stein, Executive Director
Finding 575777 (2023-004)
Significant Deficiency 2023
Management is aware of deposit requirements and has committed the resources to ensure minimum deposit requirements are met.
Management is aware of deposit requirements and has committed the resources to ensure minimum deposit requirements are met.
Finding 575776 (2023-003)
Significant Deficiency 2023
Management is aware of reporting requirements and has committed the resources to ensure timely filing for future reports.
Management is aware of reporting requirements and has committed the resources to ensure timely filing for future reports.
Identifying Number: 2023-005 Finding: The Single Audit package was not submitted to the Federal Clearinghouse within the required time period. Corrective Actions Taken or Planned: The district is delinquent in completing annual audits. The district is working to become current on financial report...
Identifying Number: 2023-005 Finding: The Single Audit package was not submitted to the Federal Clearinghouse within the required time period. Corrective Actions Taken or Planned: The district is delinquent in completing annual audits. The district is working to become current on financial reports, however it is unlikely that this will be completed for the FY25 audit. The districts goal is to be current with financial reporting deadlines with the fiscal year 2026 audited financial statements. Alan Moran, Controller and Director of Financial Reporting is responsible for this corrective action plan, and will be completed by March 31, 2027.
Finding 575294 (2023-002)
Significant Deficiency 2023
Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.
Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.
2023-002 Compliance and Internal Controls over Subrecipient Fiscal Monitoring (Significant Deficiency) Corrective Action: In accordance with 2 CFR Section 200.332, The Resource Group as the pass-through entity will ensure subrecipient fiscal monitoring is completed in 2024 to ensure compliance with ...
2023-002 Compliance and Internal Controls over Subrecipient Fiscal Monitoring (Significant Deficiency) Corrective Action: In accordance with 2 CFR Section 200.332, The Resource Group as the pass-through entity will ensure subrecipient fiscal monitoring is completed in 2024 to ensure compliance with federal and state requirements. The Finance Director is responsible for oversight and administration of fiscal monitoring. Fiscal monitoring will be conducted at least annually in accordance with HRSA Monitoring Standards 45 CFR 74.51 and 45 CFR 75.352. As a pass-through entity, fiscal monitoring will include at minimum reviews of financial performance and compliance with federal and state statues, regulations and terms and conditions. The process will include desktop/remote verification of applicable financial policy and procedures and an onsite review. A standardized monitoring tool will be used to evaluate financial compliance. The fiscal monitoring observations will result in a monitoring report, disseminated to the subrecipient within 60 days of the onsite review. Progress to date: 1. To support the financial monitoring efforts, technical assistance was received on February 5-7, 2024, from the DSHS Fiscal Support and Oversight Department. The primary objective of the visit was to discuss financial monitoring requirements as it applies to state and federal regulations, statues and terms and conditions. The standardized monitoring tool was also evaluated for compliance. 2. The Finance Director developed and implemented a comprehensive fiscal monitoring schedule for calendar year 2024. In alignment with strengthened oversight practices, onsite fiscal reviews of subrecipients commenced in February 2024. As part of the enhanced monitoring approach, the testing period for subrecipient fiscal reviews was expanded beyond the standard scope to include transactions and activities from both Fiscal Year 2022 and Fiscal Year 2023. 3. As of September 2024, the Finance Director completed 100% of fiscal monitoring visits. a. Support Documentation: to establish additional guidelines for fiscal monitoring, the Fiscal Monitoring Policy was drafted and approved by the Board on November 18, 2024. 3 Responsible Party: Finance Director, Garland Thompson Date Complete: November 18, 2024
The Municipality Administration is committed to complying with all submissions and has ensured the proper signing of an external auditor's firm to comply with such requirements.
The Municipality Administration is committed to complying with all submissions and has ensured the proper signing of an external auditor's firm to comply with such requirements.
Finding Summary: There was no formal review documented over several reports tested, some reports were not submitted timely as required by the specific award requirements, and one report did not have supporting documentation on hand. Responsible Individuals: Jay Trusty, Executive Director Corrective ...
Finding Summary: There was no formal review documented over several reports tested, some reports were not submitted timely as required by the specific award requirements, and one report did not have supporting documentation on hand. Responsible Individuals: Jay Trusty, Executive Director Corrective Action Plan: Management has reviewed the findings and taken steps in developing an internal control review process. The Commission implemented procedures to ensure all reports have proof of review and submission, as well as working towards submitting all reports timely. Anticipated Completion Date: June 2026
Finding 2023-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: The Borough is in the process of engaging addition...
Finding 2023-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: The Borough is in the process of engaging additional stakeholders to expedite the completion of future financial reports. Completion Date: September 30, 2025
Type of Finding: Significant Deficiency in Internal Control over Compliance 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with reporting requirements. During our testing, we noted the Town did not have submit the Pr...
Type of Finding: Significant Deficiency in Internal Control over Compliance 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with reporting requirements. During our testing, we noted the Town did not have submit the Project and Expenditure report, that was due by April 30, 2023. Recommendation: CLA recommends the Town implement procedures to ensure compliance with all requirements under which the Town if obligated to comply as part of their grant agreements. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: Management will implement procedures to ensure compliance with all requirements under which the Town if obligated to comply as part of our grant agreements. Name(s) of Contact Person(s) responsible for Corrective Active Plan: Kevin Gervais Jr. Planned completion date for corrective action plan: July 2025
Finding 573743 (2023-016)
Significant Deficiency 2023
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-016 Inaccurate Resource Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervis...
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-016 Inaccurate Resource Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Cases will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what cases should contain and the importance of complete and accurate record keeping. All cases will include online verifications ran timely, documented resources, income and make certain those amounts agree to information input into NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed by the caseworker and the results of those actions. Information must be updated at every application/recertification and change in circumstance adhering to Medicaid Policy. Templates have been updated to address request for information, income verifications, reasonable compatibility and to include electronic resources are ran with verification of date ran. Transfer of Asset policy and procedures will be reviewed with applicable caseworkers. TOA evaluation and clear documentation of Transfers and Resolutions must be documented. Help Desk tickets should be submitted timely if information or functionality is not working properly. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. May 1, 2024 Section III - Federal Award Findings and Question Costs (continued) 141
Finding 573742 (2023-015)
Significant Deficiency 2023
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-015 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid...
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-015 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Section III - Federal Award Findings and Question Costs (continued) April 11, 2024 Cases will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what cases should contain and the importance of complete and accurate record keeping. All cases will include online verifications ran timely, documented resources, income and make certain those amounts agree to information input into NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed by the caseworker and the results of those actions. Information must be updated at every application/recertification and change in circumstance adhering to Medicaid Policy. Templates have been updated to address request for information, income verifications, reasonable compatibility and to include electronic resources are ran with verification of date ran. CW must address all Household income and have clear documentation of request or findings. Training targeted to address error trend of Documentation of Vehicles and Rebuttals. Training targeted to address error trend of evaluation of 1/3 reduction. Information requested from OST to properly enter 1/3 reduction in NCFAST obtained. Training targeted for applicable staff to address Transfer of Asset requirements and how to address and clearly document transfers. Help Desk tickets should be submitted timely if information or functionality is not working properly. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 140
Finding 573741 (2023-014)
Significant Deficiency 2023
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-014 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Super...
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-014 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Section III - Federal Award Findings and Question Costs (continued) A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files include accurate household members, online verifications, documented sources and verifications of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. An updated template has been put in place for applications and recertification to address household members, tax filing status, electronic checks/verifications and documentation that is needed to accurately approve/deny/continue or terminate benefits. Caseworkers will need to review Determinations to ensure all eligibility is calculated accurately. All active cases regardless of program in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes will be reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. May 1, 2024 139
Finding 573740 (2023-013)
Significant Deficiency 2023
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-012 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: December 2025 Finding: 20...
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-012 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: December 2025 Finding: 2023-013 IV-D Non-Cooperation Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor At the time the determinations under audit were completed this was a requirement. However, under current policy referrals are not being enforced for cooperation with the Child Support Enforcement Agency (IV-D). Please see Administrative Letter 13/23 Due to CCU referrals are not being enforced for cooperation with the Child Support Enforcement Agency (IV-D). 5/1/2024 Caseworkers will adhere to Continuous Coverage Unwinding (CCU) Period Policy. As noted in the response to Findings 2023-001 and 2023-006, County finance staff is diligently working to improve the timeliness of transaction processing and anticipates timely completion of the FY25 audit which will resolve this finding. Melissa Miller, Interim Finance Officer Section III - Federal Award Findings and Question Costs 138
Finding 2023-002 U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: For 5 participant files, the recertification / move-in checklists were not signed by Authority staff. Res...
Finding 2023-002 U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: For 5 participant files, the recertification / move-in checklists were not signed by Authority staff. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: In addition to accounting, we also had newer staff members in the compliance department after a leadership transition with the department manager. We have conducted thorough training and discussions to help identify solutions moving forward. We will establish internal controls to ensure that all recertification/move-in checklists are signed by Authority Staff. We will work with the department manager to ensure that the control processes are being followed. Anticipated Completion Date: January 2024
U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Activities Allowed or Unallowed, Allowable Costs and Cost Principles, Eligibility, Special Test and Provisions Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Nonco...
U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Activities Allowed or Unallowed, Allowable Costs and Cost Principles, Eligibility, Special Test and Provisions Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: The Authority was not able to locate 1 of the 61 participant files selected for audit testing. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: During 2023, the Housing Choice Voucher Department moved physical locations from the 10th Floor of 1414 Santa Fe to 201 S Victoria. Also, during this time, all of the historical paper files were being scanned for digital storage. During this time, paperwork for one of the participants re-certification and inspection were misplaced and not able to be located during audit fieldwork. We do not anticipate this issue in the future since there will not be another office move, and all recertification paperwork moving forward is being scanned and attached in our software Anticipate Completion Date: January 2024
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
The Organization initially had difficulty identifying a qualified firm to carry out the Single Audit for the year ended December 31, 2023. During the first half of 2024, the Organization contacted a total of 17 firms to request quotes, in a process that proved especially difficult given that many di...
The Organization initially had difficulty identifying a qualified firm to carry out the Single Audit for the year ended December 31, 2023. During the first half of 2024, the Organization contacted a total of 17 firms to request quotes, in a process that proved especially difficult given that many did not have experience auditing Non-Profit entities or did not respond. The Organization also consulted with peer Non-Profits entities with similar budgets to obtain recommendations, and from all these efforts only one proposal was received. This prolonged search process significantly delayed the start of the audit. Nevertheless, the Organization entered into a formal agreement with a certified public accounting (CPA) firm to perform the Single Audit. In addition, as this was the Organization’s first audit, additional time was required to compile the requested documents. With a clear understanding now of the documentation requirements, the process is expected to be significantly quicker in future audits. Furthermore, the Organization has already agreed with the same firm to perform the Single Audit for subsequent years going forward.
Finding 573194 (2023-002)
Significant Deficiency 2023
Finding 2023-002: Information on the Federal Program: Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – 21.027 Compliance Requirements: Reporting – Timely Submission Type of Finding: Significant deficiency. Criteria: In accordance with 2 CFR 200.328 and the U.S. Department of the Treas...
Finding 2023-002: Information on the Federal Program: Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – 21.027 Compliance Requirements: Reporting – Timely Submission Type of Finding: Significant deficiency. Criteria: In accordance with 2 CFR 200.328 and the U.S. Department of the Treasury’s SLFRF Compliance and Reporting Guidance, recipients must submit accurate and timely Project and Expenditure Reports by the due dates established by Treasury. Additionally, under 2 CFR 200.303, recipients must establish and maintain effective internal controls over compliance with federal award requirements. Condition: The County did not submit two quarterly Project & Expenditure Reports to the U.S. Department of the Treasury within the required deadlines during 2023 for the SLFRF program. Questioned Costs: $0 Effect: Noncompliance with federal reporting requirements. However, the reports were ultimately submitted and accepted. Cause: Internal control process failure. Repeat Finding: No Recommendation: Management should implement procedures to ensure timely submission of all required SLFRF reports. Action taken in response to finding: Management will implement procedures to ensure timely submission of all required SLFRF reports.
Finding 572964 (2023-002)
Significant Deficiency 2023
FINDING 2023-002 Finding Subject: COVID‐19 ‐ Coronavirus State and Local Fiscal Recovery Funds ‐ Reporting Summary of Finding: The Elkhart County Health Department (Health Department) was awarded the Health Issues and Challenges Grant through the Indiana Department of Health (IDOH) financed through ...
FINDING 2023-002 Finding Subject: COVID‐19 ‐ Coronavirus State and Local Fiscal Recovery Funds ‐ Reporting Summary of Finding: The Elkhart County Health Department (Health Department) was awarded the Health Issues and Challenges Grant through the Indiana Department of Health (IDOH) financed through the Coronavirus State and Local Fiscal Recovery Funds The grant was funded through the American Rescue Plan Act that focused on the improvement of chronic disease, and more specifically, elevated blood lead level reduction. The Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS) each month. The submitted data included program specific metrics related to patient case management of certified Elevated Blood Lead Levels (EBLLs). A Case Manager managed all aspects of an individual patient's care. A home visit and two assessments were completed by the Case Manager and input into the NBS. Once these steps were marked as complete in the NBS, the Clinical Manager reviewed each case and compiled data along with the cost reimbursement amount into a spreadsheet. The Clinical Manager provided the spreadsheet to the Manager of Administration who then completed and submitted the reimbursement invoice to the IDOH. The reimbursement invoice was submitted without a documented oversight, review, or approval process to ensure the accuracy of the data prior to submission. Beginning in October 2022, the Health Department was required to submit program specific metrics and work plan data through RedCap software on a quarterly basis. The Case Manager was responsible for tracking and compiling the necessary information for the quarterly reports. Of the four reports tested, two reports were submitted late. In addition, the quarterly reports were submitted by the Case Manager via the RedCap software without a documented oversight, review, or approval process to ensure timely submission. Recommendation: We recommend the Health Department implement a formal oversight and review process for all data submissions to ensure accuracy and completeness before they are submitted to Indiana Department of Health (IDOH). This would involve a secondary review by a designated individual or team to verify the data. Additionally, improving workflow coordination through clearly defined roles and responsibilities for each team member would help streamline the process and prevent delays. To further improve timeliness, the Health Department should implement a tracking and reminder system for report due dates and reimbursement deadlines to ensure timely submissions. Providing staff with thorough training on reporting protocols and maintaining detailed documentation will help ensure consistent adherence to procedures. Finally, establishing accountability measures through clear roles, deadlines, and regular audits would enhance the efficiency and effectiveness of the reporting process. These steps will help ensure the Health Department meets grant requirements, maintains data accuracy, and avoids potential delays or issues in future submissions. INDIANA STATE BOARD OF ACCOUNTS 29 Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: During the prior audit we were informed of the deficiencies in our controls over the reimbursement requests submitted to the Department of Health. Unfortunately, due to the timing of the finding being brought to our attention near the end of its lifecycle we were unable to implement controls. With only one month remaining between the audit finding results and the grant’s end date, implementing the stated corrective action plan was deemed impractical. The Elkhart County Health Department has internal controls and policies for the grants that are received. This grant was very different from the other grants we have received in the past. Since the Elevated Blood Lead Level Reduction grant differed significantly from previous grants received by the Elkhart County Health Department, moving forward, if the department chooses to pursue and secure another grant with a similar scope, enhanced controls and policies will be implemented to strengthen accuracy and accountability. Specifically, the Health Department will establish a formal data review process. All data submissions will undergo an initial review, followed by a secondary verification conducted by a designated staff member. This dual review procedure will apply to all future grants of a similar nature to ensure the integrity and reliability of submitted information. The goal is to ensure there is an appropriate system of checks and balances, as well as a remediation/correction step, in place for all tasks and documentation related to grant-funded duties and invoicing. Anticipated Completion Date: Effective June 30, 2025 the Elkhart County Department of Health will implement this practice for all newly accepted grants similar in scope to the Elevated Blood Lead Level Reduction.
Finding 2023-007: Significant Deficiency - Reporting Condition: Annual ACF-696T reports were not reviewed by someone other than the preparer of the reports. Corrective Action: The Club agrees with this finding and will establish a review process in their policy and procedures to ensure that someon...
Finding 2023-007: Significant Deficiency - Reporting Condition: Annual ACF-696T reports were not reviewed by someone other than the preparer of the reports. Corrective Action: The Club agrees with this finding and will establish a review process in their policy and procedures to ensure that someone other than the person preparing the report reviews the annual ACF-696T reports before submitting them to ensure accurate reporting. Person Responsible For Corrective Action: Rhonica Via, Finance Director Anticipated Completion Date: June 30, 2025
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