Corrective Action Plans

Finding 388536 (2023-002)

Significant Deficiency 2023

State System of Higher Education, Commonwealth of Pennsylvania

PA

Student Financial Aid Reporting Significant Deficiency § 200.303

West Chester University: We have recently modified our submission schedule to ensure we have adequate time to prepare our files, conduct our pre-submission checks, and resolve errors prior to the monthly exchange of data between the National Student Clearinghouse and NSLDS. We will continue to monit...

West Chester University: We have recently modified our submission schedule to ensure we have adequate time to prepare our files, conduct our pre-submission checks, and resolve errors prior to the monthly exchange of data between the National Student Clearinghouse and NSLDS. We will continue to monitor the time it takes to complete these tasks and make any necessary modifications to support timely reporting to NSLDS. East Stroudsburg University: The University Records’ Office will implement policy and procedures to ensure students’ enrollment statuses are being reported to NSLDS through the National Student Clearinghouse. Reporting will occur on a monthly basis by means of the University Records’ Office transmitting a file to the National Student Clearinghouse. The University Records’s Office will monitor student statuses in NSLDS by randomly sampling students reported through the National Student Clearinghouse to ensure the accuracy of data being reported to NSLDS. Kutztown University: We re-evaluated our reporting procedures and worked with the Registrar’s Office to further redefine our process(es). The Registrar’s Office submits monthly transmissions to NSC (National Student Clearinghouse), who in turn updates our information to NSLDS. A new resource was identified for this responsibility, who is continuously monitoring our submissions to ensure they are accepted in a timely manner. A financial aid resource works in conjunction with the Registrar’s Office to ensure errors are addressed timely to certify the accuracy of our reporting. Cheyney University: Cheyney University of Pennsylvania currently 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, NSC only includes enrollment data for students on the enrollment roster they receive from the National Student Loan Data System (NSLDS). Cheyney University is a Heightened Cash Monitoring 2 (HCM2) institution, and students' Title IV aid/disbursements are reported differently than advance pay institutions. Students did not appear on the rosters, so NSC did not provide the enrollment data to NSLDS. While investigating the issues with enrollment reporting for our HCM2 students, Cheyney University learned that NSLDS did not receive students' enrollment from NSC. As of Spring 2023, Cheyney University has implemented procedures to report enrollment for all Title IV recipients to NSLDS. Beginning August 2024, Cheyney University will begin utilizing BANNER to create the required enrollment file and transmit the information directly to NSLDS vis EdConnect or TDClient.

View Audit 300242

Finding 388533 (2023-006)

Significant Deficiency 2023

State System of Higher Education, Commonwealth of Pennsylvania

PA

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

Pennsylvania Western University: This finding resulted from reporting issues caused by the complexity of integration. These reporting issues have been corrected and now accurately identify students who need to be reviewed for official and unofficial withdrawals. Cheyney University: In July 2023, Ch...

Pennsylvania Western University: This finding resulted from reporting issues caused by the complexity of integration. These reporting issues have been corrected and now accurately identify students who need to be reviewed for official and unofficial withdrawals. Cheyney University: In July 2023, Cheyney University signed an agreement with Financial Aid Services, LLC (FAS) to outsource many of the financial aid related functions. Return to Title IV (R2T4) was one of the functions outsourced. The process to begin outsourcing was started in December 2023. In addition to outsourcing R2T4, the Office of the Registrar will provide the Office of Student Financial Services (SFS) with a list of students who are not registered for each semester. This distribution will culminate with census reporting to PASSHE and allow SFS to notify about repayment and Return to Title IV processes. For students who apply for graduation for a particular semester, a distribution of names, identification numbers, and anticipated graduation semester, will be provided to SFS so that they can complete their exit counseling procedures.

View Audit 300242

Finding 388531 (2023-001)

Significant Deficiency 2023

Cornerstone Montgomery, Inc.

MD

Allowable Costs / Cost Principles Reporting Significant Deficiency

COVID 19 - Demonstration Programs to Improve Community Mental Health Services 93.829 Recommendation: We recommend internal controls over reporting be enhanced to ensure evidence is maintained to support the reports and review performed over the reports. Explanation of disagreement with audit findi...

COVID 19 - Demonstration Programs to Improve Community Mental Health Services 93.829 Recommendation: We recommend internal controls over reporting be enhanced to ensure evidence is maintained to support the reports and review performed over the reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are in the process of re-evaluating the reporting process to ensure documentation is maintained to support the reporting requirements. Name of the contact person responsible for corrective action: Lisa Katz, Chief Program Officer Planned completion date for corrective action plan: Currently underway and planned to be completed by June 30, 2024.

View Audit 300238

Finding 388520 (2023-004)

Significant Deficiency 2023

City of Richmond

VA

Reporting Subrecipient Monitoring Significant Deficiency § 200.303

Recommendation: We recommend that the Department develop internal controls and procedures to ensure that all required subawards are reported timely to FSRS no later than the end of the month following the month of issuance in accordance with FFATA reporting requirements. Explanation of disagreement ...

Recommendation: We recommend that the Department develop internal controls and procedures to ensure that all required subawards are reported timely to FSRS no later than the end of the month following the month of issuance in accordance with FFATA reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: HCD has made it part of a dedicated staff member to input the data into the FSRS system on a timely basis. HCD will also update their process so that all applicants must provide their UEI number. Name(s) of the contact person(s) responsible for corrective action: Sherrill Hampton Planned completion date for corrective action plan: 7/31/24

View Audit 300220

Finding 388519 (2023-003)

Significant Deficiency 2023

City of Richmond

VA

Questioned Costs Subrecipient Monitoring Period of Performance § 200.303 § 200.308 § 200.309 § 200.403

Recommendation: We recommend that the Department review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. A...

Recommendation: We recommend that the Department review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A correction will be made to reduce the request by the overstated (by 1 day) amount in the 3/31 payroll report. A credit was issued to FEMA for the amount of $19,871.26 on Monday March 13, 2023 in relation to the finding noted. Name(s) of the contact person(s) responsible for corrective action: Angelia Adediran, Deputy Director City of Richmond Fire and Emergency Services

View Audit 300220 Questioned Costs: $1

Finding 388512 (2023-003)

Significant Deficiency 2023

Dupage Housing Authority

IL

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Finding 2023-003: Overpayments to Landlords (Significant Deficiency) Corrective Action Plan: DHA Management has worked with our financial institution to ensure that the positive pay function is working and duplicate payments will not be posted to Landlord accounts. Name of Responsible Person: Cheron...

Finding 2023-003: Overpayments to Landlords (Significant Deficiency) Corrective Action Plan: DHA Management has worked with our financial institution to ensure that the positive pay function is working and duplicate payments will not be posted to Landlord accounts. Name of Responsible Person: Cheron Corbett Completion Date: July 31, 2023

View Audit 300217

Finding 388511 (2023-002)

Significant Deficiency 2023

Dupage Housing Authority

IL

HUD Housing Programs Internal Control / Segregation of Duties Reporting

Finding 2023-002: Late Submission of Unaudited Data to REAC (Significant Deficiency) Corrective Action Plan: Due to the abrupt quitting of our previous Comptroller cause a delay in the submission of our unaudited financials. DHA has hired a new Comptroller and we have monthly meetings to ensure that...

Finding 2023-002: Late Submission of Unaudited Data to REAC (Significant Deficiency) Corrective Action Plan: Due to the abrupt quitting of our previous Comptroller cause a delay in the submission of our unaudited financials. DHA has hired a new Comptroller and we have monthly meetings to ensure that all accounting data is being recorded timely. This will allow us to submit timely financials to HUD. . Name of Responsible Person: Cheron Corbett, Executive Director Projected Completion Date: December 31, 2024

View Audit 300217

Finding 388469 (2023-004)

Significant Deficiency 2023

Saint Elizabeth University

NJ

Questioned Costs Student Financial Aid Significant Deficiency

Unofficial Withdrawals Planned Corrective Action: The University will run zero credit reports at the end of each semester to ensure all potential unofficial withdrawals are followed up on so that R2T4’s are completed timely when required. Person Responsible for Corrective Action Plan: Nicholas Cap...

Unofficial Withdrawals Planned Corrective Action: The University will run zero credit reports at the end of each semester to ensure all potential unofficial withdrawals are followed up on so that R2T4’s are completed timely when required. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: June 30th, 2024

View Audit 300191 Questioned Costs: $1

Finding 388467 (2023-003)

Significant Deficiency 2023

Saint Elizabeth University

NJ

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

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates...

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates reflect the actual disbursement date. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024

View Audit 300191

Finding 388462 (2023-002)

Significant Deficiency 2023

Saint Elizabeth University

NJ

Subrecipient Monitoring Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University’s IT Department will work to update procedures and controls to ensure any federal regulations of the FTC Safeguards Rule (16 CFR § 314.4(b)(1) - 16 CFR § 314.4(i)) that were found to be in partial compliance are reme...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University’s IT Department will work to update procedures and controls to ensure any federal regulations of the FTC Safeguards Rule (16 CFR § 314.4(b)(1) - 16 CFR § 314.4(i)) that were found to be in partial compliance are remediated and brought into compliance. Some of these have already been remediated. We will work with other departments who administer third party vendor accounts to enforce MFA where there are gaps. A penetration test and the standing up of a tool to continuously monitor our network internally and those of third party vendors are already in startup phases Our information security program and risk assessment will be updated to reflect any recommendations offered by our auditors to fill any existing gaps in the 2023 audit. Person Responsible for Corrective Action Plan: Ron Loneker, Jr., Director, IT Special Projects Anticipated Date of Completion: May 31, 2024

View Audit 300191

Finding 388461 (2023-002)

Significant Deficiency 2023

Brooklyn Law School

NY

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

2023-002 Enrollment Reporting – Significant Deficiency United States Department of Education— ALN 84.268 Federal Direct Student Loans Program Criteria: Per CFR §658.309, unless it expects to submit its next updated enrollment report to the Secretary within the next 60 days, a school must notify the ...

2023-002 Enrollment Reporting – Significant Deficiency United States Department of Education— ALN 84.268 Federal Direct Student Loans Program Criteria: Per CFR §658.309, unless it expects to submit its next updated enrollment report to the Secretary within the next 60 days, a school must notify the Secretary within 30 days after the date the school discovers that: (i) a loan under title IV of the Act was made to or on behalf of a student who was enrolled or accepted for enrollment at the school, and the student has ceased to be enrolled on at least a half-time basis or failed to enroll on at least a half-time basis for the period for which the loan was intended; or (ii) a student who is enrolled at the school and who received a loan under title IV of the Act has changed his or her permanent address. Condition: For one out of 25 students sampled, the effective date reported in NSLDS was incorrect. For four out of 25 students sampled, the status change was not reported in NSLDS in the next enrollment report or within 30 days of the date of determination. Cause: The Law School does not have a formalized policy to address enrollment reporting for summer terms. Effect: Enrollment reporting was inaccurate. Federal loan servicers utilize this information to determine the appropriate status for repayment terms and as such, had incorrect information. Enrollment reporting was not submitted within the required time frame. Questioned Costs: None. Context: See condition above. Recommendation: We recommend the Law School enhance their procedures and formalize a written policy for all terms of enrollment reporting. Corrective Actions Taken: Julie Brown, the Registrar will be given access to the NSLDS database to verify the information submitted through the National Student Clearinghouse is reported completely and accurately, particularly in relation to enrollment statuses that change during the non-required summer terms. This is part of an ongoing process as this information is updated multiple times per year. The Registrars Office will also draft a policy including timelines for uploading information to the National Student Clearinghouse and dates for verification of information in NSLDS. Responsible party: Julie Brown, Registrar. 718-780-7918 julie.brown@brooklaw.edu

View Audit 300177

Finding 388460 (2023-001)

Significant Deficiency 2023

Brooklyn Law School

NY

Questioned Costs Eligibility Significant Deficiency

2023-001 Program Eligibility—Significant Deficiency United States Department of Education - ALN 84.268 Federal Direct Student Loans Program Criteria: Students who receive federal student aid are required to be enrolled in an eligible program. Eligible programs must be included in an institution’s ac...

2023-001 Program Eligibility—Significant Deficiency United States Department of Education - ALN 84.268 Federal Direct Student Loans Program Criteria: Students who receive federal student aid are required to be enrolled in an eligible program. Eligible programs must be included in an institution’s accreditation and authorized by the State and the US Department of Education. Condition: The Law School disbursed federal student aid to 63 students, totaling approximately $2,115,747, enrolled in an ineligible program; the LL.M. program. Context: The impact was to 63 students over a four-year period. Cause: The Master of Laws (LL.M) Program was included in the Law School’s ECAR which was approved by the Department of Education. The Law School’s accreditation by the American Bar Association does not cover programs outside of the Juris Doctorate program. As such, the LL.M program was not properly accredited and therefore not an eligible program. The ECAR was subsequently amended to remove this program. Effect: Federal student aid funds were inappropriately disbursed to students in an ineligible program which resulted in the Law School entering into a settlement agreement with the U.S. Department of Education pursuant to which the Law School reimbursed and paid a fine to the US Department of Education. Questioned Costs: $2,115,747 Recommendation: We recommend the Law School review new or modified programs to ensure program eligibility requirements are met. Corrective Actions Taken: Upon notification from Department of Education regarding this concern, the Law School discontinued disbursement of Title IV funds to students of the LL.M. program and will not disburse those funds to students of that program until it receives additional accreditation. The Law School is currently working on obtaining accreditation from the Middle States Commission on Higher Education for its existing LL.M. and future Master’s degree programs. Responsible Person: David D. Meyer, President and Dean, (718) 780-7901, david.meyer@brooklaw.edu

View Audit 300177 Questioned Costs: $1

Finding 388443 (2023-014)

Significant Deficiency 2023

State of Hawaii, Department of Accounting and General Services

HI

Subrecipient Monitoring Reporting Significant Deficiency

2023‐014 – Reporting (Significant Deficiency) State Department of Defense AL Number: 97.067 Program Title: Homeland Security Grant Program Condition The auditing firm selected three subawards that were executed between July 1, 2022 – June 30, 2023, noting that FFATA reports for the selected subaward...

2023‐014 – Reporting (Significant Deficiency) State Department of Defense AL Number: 97.067 Program Title: Homeland Security Grant Program Condition The auditing firm selected three subawards that were executed between July 1, 2022 – June 30, 2023, noting that FFATA reports for the selected subawards were not filed timely. Current Status of Corrective Action Plan Concur. It is our commitment to address this issue promptly and implement necessary measures to prevent its recurrence. We understand the importance of accurate and timely data entry in the FFATA portal for federal awards and sub awards. In response to this issue, we have developed a corrective action plan to address the root causes and prevent similar occurrences in the future: -Review of Process: We will conduct a thorough review of our current process for entering funding amounts into the FFATA portal to identify any inefficiencies or gaps in the process. -Training and Awareness: We will provide additional training to other personnel in the grant section to ensure that there is continuity in the tasks. This will include reinforcing the importance of adhering to established deadlines and protocols. -Implement Reminders: We will implement automated reminders and notifications to alert grant staff members via shared Microsoft Outlook Calendar of impending deadlines for entering new federal award into the FFATA portal. These reminders will serve as a proactive measure to prevent delays and ensure timely completion of tasks. Lastly, reminder indicators such as; receiving the official grant award and executing a memorandum of agreement with sub recipients will be an indicator for action to process FFATA reporting. The FFATA information and process already exists in our Homeland Security Procedural Manual (Page 49) that we maintain annually. We will continue to maintain and make any necessary revisions if there are any changes. Person Responsible Glen Badua, Grants Manager Anticipated Date of Completion February 20, 2024

View Audit 300162

Finding 388434 (2023-011)

Significant Deficiency 2023

State of Hawaii, Department of Accounting and General Services

HI

Matching / Level of Effort / Earmarking Subrecipient Monitoring Significant Deficiency

Finding No. 2023‐011 – Earmarking (Significant Deficiency) State Department of Labor and Industrial Relations AL Numbers and Program Title: 17.258 – WIOA Adult Program 17.259 – WIOA Youth Activities 17.278 – WIOA Dislocated Worker Formula Grant (WIOA Cluster) Condition The auditing firm noted the fo...

Finding No. 2023‐011 – Earmarking (Significant Deficiency) State Department of Labor and Industrial Relations AL Numbers and Program Title: 17.258 – WIOA Adult Program 17.259 – WIOA Youth Activities 17.278 – WIOA Dislocated Worker Formula Grant (WIOA Cluster) Condition The auditing firm noted the following instances of noncompliance: -A total of 15.61% of funds were allocated for employment and training activities for adults and dislocated workers. -A total of 74.60% of funds were allocated for services to out of school youth. Current Status of Corrective Action Plan Concur. -Administrative Services Office (ASO) has communicated with Workforce Development Division (WDD) that no more than 15% of funds shall be allocated to provide employment training activities for Adults and Dislocated Workers. If there are recaptured funds to spend from the local areas for the program year, ASO and WDD will make sure that recaptured funds will not exceed the maximum requirements of 15%. -WDD shall monitor the progress of subrecipients to meet the minimum 75% expenditure for out of school youth. If necessary, a monthly or bi‐monthly meeting with subrecipients shall be scheduled to monitor the progress and take pro‐active recommendations and action to meet the requirements. Person Responsible Maricar Pilotin‐Freitas, Workforce Development Division Administrator Anticipated Date of Completion March 2024

View Audit 300162

Finding 388430 (2023-009)

Significant Deficiency 2023

State of Hawaii, Department of Accounting and General Services

HI

Questioned Costs Eligibility Significant Deficiency

Finding No. 2023‐009 – Eligibility (Significant Deficiency) State Department of Labor and Industrial Relations AL Number: 17.225 Program Title: Unemployment Insurance Condition The audit identified two payments where the recipients did not make the minimum number of work search contacts. Current Sta...

Finding No. 2023‐009 – Eligibility (Significant Deficiency) State Department of Labor and Industrial Relations AL Number: 17.225 Program Title: Unemployment Insurance Condition The audit identified two payments where the recipients did not make the minimum number of work search contacts. Current Status of Corrective Action Plan Concur. Hawaii UI issued a memo, dated September 22, 2023, reminding the local offices of the minimum work search requirements under Administrative Rule 12‐5‐35(c) and for the adjudication unit to conduct a fact‐finding as to the reasons for the claimant’s non‐compliance. Hawaii UI is currently working on a project to enhance the work search process and requirements using a grant awarded to UI by US Department of Labor. The project will allow expansion to the work search reporting requirement on the front‐end of the online weekly claim certification process to include employer job search details. The process entails the use of Behavioral Insight techniques to encourage accurate reporting of the work search requirement and provide a log of their work search efforts. These enhancements will help claimants better understand UI program requirements including: -What claimants should report and why, -The reporting expectations at various decision points throughout the certification process while they still have time to meet the requirements, -Convey the consequences of intentionally providing false information or making mistakes during reporting, and -Imposing a denial of benefits for weeks in which the claimant does not meet the work search eligibility requirement. Person Responsible Sheryl Maligro, UI Program Supervisor Anticipated Date of Completion The enhancements to the Work Search Process are anticipated to be completed in June 2024.

View Audit 300162 Questioned Costs: $1

Finding 388427 (2023-006)

Significant Deficiency 2023

State of Hawaii, Department of Accounting and General Services

HI

Subrecipient Monitoring Reporting Significant Deficiency

Finding No. 2023‐006 – Reporting (Significant Deficiency) State Department of Land and Natural Resources AL Number: 15.615 Program Title: Cooperative Endangered Species Conservation Fund Condition A prime recipient of a federal award is required to file a Federal Funding Accountability and Transpar...

Finding No. 2023‐006 – Reporting (Significant Deficiency) State Department of Land and Natural Resources AL Number: 15.615 Program Title: Cooperative Endangered Species Conservation Fund Condition A prime recipient of a federal award is required to file a Federal Funding Accountability and Transparency Act (FFATA) report to the FFATA Subaward Reporting System (FSRS) by a specific period for any subaward greater than or equal to $30,000. The auditing firm haphazardly tested the one subaward executed in FY 2023 and noted FFATA report was not completed timely. Current Status of Corrective Action Plan Concur. DLNR has procedures in place for the submission of FFATA reports and will ensure that the reports are filed timely. Person Responsible Cynthia C. Gomez, Fiscal Management Officer Anticipated Date of Completion Completed.

View Audit 300162

Finding 388424 (2023-002)

Significant Deficiency 2023

Catholic Community Services of Southern Arizona, Inc.

AZ

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking

Secondary Review of Billings (Significant Deficiency) Federal Agency: U.S. Department of Health and Human Services Program Title: Child Care and Development Block Grant Assistance Listing Number: 93.575 Federal Award Source: Pass-Through Funding Pass-Through Entity: Arizona Department of Economic S...

Secondary Review of Billings (Significant Deficiency) Federal Agency: U.S. Department of Health and Human Services Program Title: Child Care and Development Block Grant Assistance Listing Number: 93.575 Federal Award Source: Pass-Through Funding Pass-Through Entity: Arizona Department of Economic Security Pass-Through Identifying Number: SX222367 Criteria – Section §200.303 of the Uniform Guidance states that a non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition and Context – During our audit of allowable activities, we noted the Organization did not conduct a secondary internal supervisory review of the monthly billings for this program prior to submission to the funding source. Cause and Effect – Due to a shortage in staff, all 12 monthly billings for this program were prepared by one individual and were not reviewed and approved by secondary supervisory personnel. Questioned Costs – None identified. Recommendation – We recommend that the Organization improve its internal controls over the preparation of billings for this program to ensure all billings are reviewed and approved by secondary supervisory personnel. View of Responsible Officials: We agree with the finding. We have implemented procedures to ensure secondary reviews of all billings. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: CCS will improve its internal controls over the preparation of all billings. Effective April 1, 2024, Tammy Gallegos, CCS Accounting Manager, will make certain all billings are reviewed and approved by a secondary supervisor. The Accounting Manager will check off and sign off on a listing of all billings in an effort to ensure and document that 1) the billings were reviewed by a secondary supervisor, 2) the billings were submitted to the payers, and 3) the billings were submitted on a timely manner.

View Audit 300150

Finding 388423 (2023-001)

Significant Deficiency 2023

Catholic Community Services of Southern Arizona, Inc.

AZ

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring

Procurement (Significant Deficiency) and Compliance Federal Agency: U.S. Department of Homeland Security Program Title: Emergency Food & Shelter National Board Program (“EFSP”) Assistance Listing Number: 97.024 Federal Award Source: Pass-Through Funding Pass-Through Entity: Pima County Pass-Through...

Procurement (Significant Deficiency) and Compliance Federal Agency: U.S. Department of Homeland Security Program Title: Emergency Food & Shelter National Board Program (“EFSP”) Assistance Listing Number: 97.024 Federal Award Source: Pass-Through Funding Pass-Through Entity: Pima County Pass-Through Identifying Number: CT-GMI-21-452 Criteria – Section §200.320 of the Uniform Guidance requires that when the value of the procurement for property or services under a Federal financial assistance award exceeds the Simplified Acquisition Threshold, a formal procurement method is required, such as a sealed bid or proposal. In addition, these formal procurement methods require public advertising. Condition – During our audit of the procurement requirements for the EFSP program, we noted the Organization utilized a vendor who in total was paid more than the Simplified Acquisition Threshold; however, the Organization did not utilize a formal procurement method in selecting this vendor as required by their policies and the Uniform Guidance. Cause – The finding appears to be the result of an immediate need to obtain services and an oversight to subsequently conduct a formal procurement method. Effect and Context – By not adhering to a formal procurement method, the Organization may or may not have chosen the best vendor to provide the services. There was only one vendor whose payments exceeded the Simplified Acquisition Threshold during the audit period. Our sample was a statistically valid sample. Questioned Costs – None identified. Recommendation – We recommend the Organization provide periodic training to its program staff regarding procurement requirements per the Uniform Guidance and consider modifying its procurement related internal controls to ensure all staff follow the Organization’s procurement policies. View of Responsible Officials: We are in agreement with the finding and are in the process of updating our procedures to mitigate issues in the future. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: CCS has updated its purchasing policy as of March 22, 2024. The purchasing policy will be included as part of the program staff’s required 2024 annual training effective April 1, 2024. The Relias Learning platform will be the mechanism used for this training. Staff will be given a deadline of April 30, 2024 to complete this training. In addition, Tammy Gallegos, the CCS Accounting Manager will monitor large purchases by vendor on a monthly basis. This is to ensure that vendors providing goods or services to CCS that meet or exceed the Single Acquisition Threshold per federal regulations follow a formal procurement method, such as soliciting bids. Bids will be kept with the vendors’ file in the CCS Business Office.

View Audit 300150

Finding 388409 (2023-002)

Significant Deficiency 2023

Community Youth Advance

MD

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking

Planned Corrective Actions: The Community Youth Advance Interim Executive Director will make updates to the Employee Handbook and create a Standard Operating Procedures manual that outlines key responsibilities with regard to record keeping and reporting that will ensure continuity and stability dur...

Planned Corrective Actions: The Community Youth Advance Interim Executive Director will make updates to the Employee Handbook and create a Standard Operating Procedures manual that outlines key responsibilities with regard to record keeping and reporting that will ensure continuity and stability during times of leadership and staff transition. This will be reviewed with staff and our accounting firm to ensure it is comprehensive and addresses the organization’s needs and the recommendations of this audit. The Board of Directors will then review and give final approval of these documents. Name of the contact Person responsible for corrective action: Danielle Middlebrooks, Interim Executive Director, Community Youth Advance Board of Directors (Cassius Priestly, Chair) and Goldin Group CPAs Planned completion date for corrective action plan: The Standard Operating Procedures Manual and the Updated Community Youth Advance Employee Handbook will be completed and approved by June 30, 2024, to take effect July 1, 2024.

View Audit 300144

Finding 388328 (2023-002)

Significant Deficiency 2023

Memorial Hospital of Laramie County D/b/a Cheyenne Regional Medical Ce

WY

Allowable Costs / Cost Principles Eligibility Period of Performance § 200.303

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: The Medical Center was not able to provide supporting invoices for t...

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: The Medical Center was not able to provide supporting invoices for two of the testing selections. An additional selection contained a keying error. Responsible Individuals: Amy Spieker, Director Community Health and Analysis, and Erika Novick, Operations Manager Corrective Action Plan: The Program Director and Operations Manager will ensure all invoices are properly submitted and approved prior to including the expenses in the reimbursement requests. Program Director/Director of Community Health and Analysis will review draws/invoices to ensure amounts on supporting documents agree to the amounts submitted in the reimbursement requests. Finance will also revise Corporate Card Policy by June 30, 2024, to include expense reports being submitted in a timely manner. Finance will review open expense reports with card holder and their supervisor monthly. Anticipated Completion Date: April 1, 2024

View Audit 300118

Finding 388327 (2023-001)

Significant Deficiency 2023

Memorial Hospital of Laramie County D/b/a Cheyenne Regional Medical Ce

WY

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: There was no evidence retained that the Medical Center’s compliance ...

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: There was no evidence retained that the Medical Center’s compliance reports submitted to Equal Justice and Wyoming Department of Family Services (WDFS) were reviewed and approved prior to submission. Responsible Individuals: Amy Spieker, Director Community Health and Analysis Corrective Action Plan: The Program Director will review and approve the data input into the monthly and quarterly reports. If red flags are identified, adjustments will be made. Once the reports are deemed satisfactory, the Program Director will electronically sign off on the report to denote review and approval for submission to awarding agency. Anticipated Completion Date: April 1, 2024

View Audit 300118

Finding 388301 (2023-001)

Significant Deficiency 2023

Maranatha Baptist University

WI

Student Financial Aid Internal Control / Segregation of Duties Reporting

Student Financial Aid Cluster – Assistance Listing No. 84.063 & 84.268 Recommendation: We recommend that the University review its enrollment certification batches subsequent to being posted by NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Ac...

Student Financial Aid Cluster – Assistance Listing No. 84.063 & 84.268 Recommendation: We recommend that the University review its enrollment certification batches subsequent to being posted by NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will submit a batch update for the individuals currently labeled with an incorrect withdrawal status. The batch process will also be updated to include a graduates-only file submitted after the subsequent enrollment conferrals are complete. Name of the contact person responsible for corrective action: Donald Donovan, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2024

View Audit 300098

Finding 388300 (2023-001)

Significant Deficiency 2023

Santa Barbara Community College District

CA

Questioned Costs Subrecipient Monitoring Eligibility

Response Two different sets of guidelines were issued for the Coronavirus State and Local Fiscal Recovery Funds. The first set of guidelines were issued in March 2021 (Attachment A). These first set of guidelines allowed undocumented students to receive the award #4 (Attachment A). These are the g...

Response Two different sets of guidelines were issued for the Coronavirus State and Local Fiscal Recovery Funds. The first set of guidelines were issued in March 2021 (Attachment A). These first set of guidelines allowed undocumented students to receive the award #4 (Attachment A). These are the guidelines that were used to award students monies from this fund. During the audit, it was noted that SBCC incorrectly awarded undocumented students with monies from the Coronavirus State and Local Fiscal Recovery Funds. SBCC was not aware at the time of awarding these monies that a second guidance memo had been issued by the Community Colleges of California Chancellor’s Office (CCCCO) on Friday, January 21,2022 (Attachment B). The updated memo clearly stated that undocumented students were no longer eligible for these funds. SBCC had not updated its protocols to match the second memo due to staffing issues within th e financial aid office. Specifically, the manager of the Financial Aid Office was out on disability leave from January 26 through September 28, 2022. However, no funds were awarded during this absence. Within the new guidance, a new process stated how to corrects awards given to candidates originally eligible (undocumented students) under the first memo, but no longer eligible under the second memo. Per the second memo, any incorrectly awarded funds under the first policy were to be replaced with other funds that undocumented students are eligible to receive. Corrective Action To correct the incorrect awarding of funds to ineligible candidates, SBCC cancelled the awards to now ineligible recipients of Early Action Fund (EMASS/SRFR) and replace d them with awards from AB19 monies, which were rolled over from 22-23. SBCC also used monies from remaining HEERF/CARES funds, which allowed for awards to undocumented students. In total, SBCC corrected 16 awards totaling $48,000. SBCC’s records now reflect that no undocumented students received Coronavirus State and Local Fiscal Recovery Funds. Going forward, SBCC is now awarding under the correct guidelines. No further awards have been made to undocumented students. The fund is winding down and will be spent in full by the end of the 23-24 fiscal year.

View Audit 300097 Questioned Costs: $1

Finding 388299 (2023-001)

Significant Deficiency 2023

Jobpath, Inc.

AZ

Subrecipient Monitoring Reporting Significant Deficiency

Reporting (Significant Deficiency) and Federal Agency: U.S. Department of Treasury Program Title: Coronavirus State and Local Fiscal Recovery Funds (“CSLFRF”) Assistance Listing Number: 21.027 Federal Award Source: Pass-Through Funding Pass-Through Entity: State of Arizona Pass-Through Identifying...

Reporting (Significant Deficiency) and Federal Agency: U.S. Department of Treasury Program Title: Coronavirus State and Local Fiscal Recovery Funds (“CSLFRF”) Assistance Listing Number: 21.027 Federal Award Source: Pass-Through Funding Pass-Through Entity: State of Arizona Pass-Through Identifying Number: GR-ARPA-JP-030122-01 Criteria – The pass-through entity’s grant agreement with the Organization requires that the Organization submit quarterly summary reports with the numbers of program participants no later than 15th of the month following each Fiscal Quarter. Condition – During our audit of the reporting requirements for the CSLFRF program, we requested quarterly summary reports and noted that they were not created nor submitted. Cause – The finding appears to be the result of staffing turnover at the Organization. The former Grants Manager resigned in May 2023 with position being absorbed by Director of Finance in July 2023. Effect and Context – Four quarterly summary reports were not submitted. Questioned Costs – None identified. Recommendation – We recommend the Organization implement policies and procedures to ensure timely and accurate reporting of required program reports. View of Responsible Officials: We are in agreement with the finding and are in the process of updating our procedures to mitigate the issues noted in the future. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: The Director of Finance will create a grant reporting checklist so that in the event of staff turnover, no reporting requirements are overlooked in the transition. The checklist will be created by the next quarterly grants meeting scheduled for April 4th. Subsequently, the Director of Finance will update the checklist every time a new grant is received and include a status review of all grant reporting requirements in the weekly Finance meeting and quarterly Grant meeting agendas, both of which are attended by the CEO, Director of Operations, Director of Development, and Director of Finance.

View Audit 300092

Finding 388290 (2023-001)

Significant Deficiency 2023

Shasta County Office of Education

CA

Subrecipient Monitoring Eligibility School Nutrition Programs

This error was due to clerical oversight. The program has reviewed the processes in place with the appropriate staff and has implemented additional layers of review to ensure compliance.

View Audit 300075

Corrective Action Plans

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