Corrective Action Plans

Finding 47805 (2022-058)

Significant Deficiency 2022

State of Oregon

OR

Questioned Costs Eligibility Period of Performance

2022-058 Department of Human Services Perform timely reconciliations of refinanced OR-Kids transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.667 Social Services Block Grant Federal Award Numbers and Years: 2101ORSOSR, 2021; 22...

2022-058 Department of Human Services Perform timely reconciliations of refinanced OR-Kids transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.667 Social Services Block Grant Federal Award Numbers and Years: 2101ORSOSR, 2021; 2201ORSOSR, 2022 Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: $1,308,457 (likely) Criteria: 42 USC 1397a(c); 45 CFR 75.386a(2); 45 CFR 96.30b(2) According to federal requirements, to be eligible for federal funding, expenditures must be expended in the fiscal year allotted or in the succeeding fiscal year (period of performance). Additionally, federal post-closeout requirements stipulate the return of any funds due because of later refunds, corrections, or other transactions. As part of the grant closeout process, block grants also require the grantees to report the total funds expended and the date of the last expenditure. Grant closeout is the process by which the federal awarding agency determines that all applicable administrative actions and all required work have been completed. Social Services Block Grant (SSBG) has expenditures originating from the child welfare system, OR-Kids. OR-Kids is used to manage placements, eligibility, payments, and other case information. When various corrections are initiated, OR-Kids can re-process transactions as far back as January 1, 2008. For some placement corrections, OR-Kids processed the recovery of the funds in a state grant (Miscellaneous Other Fund grant), instead of the federal grant. To date, the department has not completed permanent fixes to the OR-Kids system to prevent these re-processing errors from occurring. During fiscal year 2022, the department was reconciling the Miscellaneous Other Fund grant and identified refunds related to SSBG. The refinanced expenditures reduced the amount of SSBG expenditures originally reported in closed grant awards. Instead of submitting a refund, the department identified expenditures recorded in subsequent grants that could have been used to backfill the reduction of expenditures. Allowable expenditures, that met the period of performance, were subsequently moved. To illustrate, a total of $1.3 million of expenditures were moved in the accounting system from grant award 21 (federal fiscal year 2021) to grant award 20. The department then moved expenditures totaling $1.2 million from grant award 20 to grant award 19. This process continued for all grant awards going back to grant award 11 (federal fiscal year 2011). The table below illustrates the movement of expenditures between grant awards. ?See Corrective Action Plan for Table? Although the department only moved expenditures that qualified for each respective period of performance, we question whether the federal awarding agency would allow the department to backfill the $1.3 million of expenditures in question after grant closeout had been completed. We recommend department management conduct more timely reconciliations of OR-Kids refinancing adjustments to ensure adjustments are made during the related periods of performance. We further recommend management work with its federal awarding agency to determine if it is appropriate to backfill program expenditures between grants to account for the reduction in expenditures created by the reconciliation process. If not appropriate, the questioned costs should be repaid to the federal awarding agency. MANAGEMENT RESPONSE: The agency disagrees with this finding. SFMA grant phase is an internal tracking mechanism only and is not mandated by ACF. None of the expenditures observed were moved into or out of the period of performance for which they originally qualified for. SSBG awards have a two-year period of performance for claiming. As a result, there is an overlap between internal phases where expenditures qualify for two at any given time. Assignment of phase in SFMA is based on internal balancing needs to ensure claiming is not over or under the award for that period. Prior period adjustments occur periodically and are debited or credited to the phase they were originally recorded under. Should those adjustments cause a phase to become under or over reported, the assigned phase in SFMA is adjusted to maintain consistency between SFMA expenditures and the SF-425 report provided to ACF. If a prior period increasing expenditure is outside the period of performance, it is moved to non-reportable and state only funding. Anticipated Completion Date: N/A Contact: Fariborz Pakseresht, Oregon Department of Human Services Director

View Audit 45093 Questioned Costs: $1

Finding 47798 (2022-040)

Significant Deficiency 2022

State of Oregon

OR

Questioned Costs Eligibility Significant Deficiency

2022-040 Department of Human Services Improve controls to ensure eligibility criteria are met Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, ...

2022-040 Department of Human Services Improve controls to ensure eligibility criteria are met Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $9,569 (known); $931,750 (likely) Criteria: 45 CFR 264.1; Oregon TANF State Plan The State of Oregon Temporary Assistance for Needy Families (TANF) State Plan (Plan) defines financial neediness criteria with its adjusted income limit tables. Federal regulations establish 60 cumulative months as the length of time a client may receive federal TANF assistance. The department uses its case management system, Oregon Eligibility (ONE), to count federal-eligible benefit months, and when 60 months is reached, an indicator is sent to the financial subsystem to change federal funding to state funding. From a population of 105,267 TANF benefit payments recorded in ONE, we randomly selected a sample of 40 and two additional individually significant payments for testing. We found: One sample?s financial eligibility information included a disaster relief benefit without details showing the date of payment and the covered time period. As a result, auditors and the department are unable to determine if this case met financial eligibility criteria, resulting in questioned costs of $1,311. One individually significant case?s child support and spousal support were entered incorrectly into ONE. The countable income at time of certification did not meet the adjusted income limit, making the client ineligible for TANF benefits. Questioned costs for this case total $8,258. We recommend department management ensure federally-funded client benefits are paid on behalf of eligible individuals, and documentation is retained to support eligibility decisions. We also recommend department management correct the identified error cases and reimburse the federal agency for questioned costs. MANAGEMENT RESPONSE: We agree with this recommendation. The Department will communicate to eligibility staff the importance of reviewing information reported by the applicant compared to information received from a third-party and direct staff to case note in the ONE system how the discrepancy was reconciled. The Department will also communicate the requirement to maintain eligibility records in both case notes and electronic file when applicable. The Department will review the cases cited and make an appropriate referral to the Overpayment Recovery Unit. Overpayments recouped can then be adjusted by Office of Financial Services to credit the TANF federal grant rather than reimbursing, per instructions outlined in TANF-ACF-PI-2006-03. Anticipated Completion Date: October 31, 2023 Contact: Annette Palmer, TANF Program Manager

View Audit 45093 Questioned Costs: $1

Finding 47791 (2022-053)

Significant Deficiency 2022

State of Oregon

OR

Reporting Material Weakness Significant Deficiency § 200.328

2022-053 Oregon Health Authority Improve financial reporting accuracy Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK00...

2022-053 Oregon Health Authority Improve financial reporting accuracy Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK000541, 2020 (COVID-19); 6 NU50CK000541, 2021 (COVID-19) Compliance Requirements: Reporting Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: 2021-022 Questioned Costs: N/A Criteria: 2 CFR 200.328 In response to the COVID-19 pandemic, the Centers for Disease Control (CDC) awarded states substantial funds for the purpose of addressing the pandemic at the state level. Among other requirements, states are required to submit monthly financial reports to the CDC providing totals spent on travel, payroll, equipment, and other categories. During the fiscal year 2021 audit, we reported a material weakness relating to the accuracy of the amounts reported to the CDC. The same issue persisted throughout fiscal year 2022. As of June 30, 2022, the department had not taken the necessary actions to implement the prior recommendations and had not fully corrected the reports submitted in fiscal years 2021 and 2022. However, as of March 2023, the department had implemented the appropriate corrective actions and the previously inaccurate reports have been updated, including the reports for fiscal year 2022. Audit standards require that we report on the status as of June 30, 2022. We recommend department management maintain the necessary internal controls to ensure the monthly financial reports are accurate and agree to the accounting records. MANAGEMENT RESPONSE: We agree with this recommendation. As you note in your audit letter, our financial reporting accuracy had been remedied for all historical and current reports by March 2023. Unfortunately, these improvements were not in place by June 30, 2022 and, for that reason, a finding was noted. Corrective action plan: ? All monthly financial reporting has been assigned to our Fiscal Analyst ? The Fiscal Analyst submits monthly financial reports and the query used to generate the reports to the Office of Financial Services (OFS) for review and approval ? The Fiscal Analyst revises monthly financial reports based on OFS feedback ? Following OFS approval, monthly financial reports are entered into CAMP by an ELC administrative staff member and verified by a second team member Anticipated Completion Date: March 31, 2023 Contact: Merry Carlson, ELC Contracts Manager

View Audit 45093

Finding 47790 (2022-052)

Significant Deficiency 2022

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303

2022-052 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU...

2022-052 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK000541, 2021 (COVID-19) Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $35,416 (known) (COVID-19) Criteria: 2 CFR 200.303 As part of our testing, we reviewed expenditures charged to the program to ensure they were properly approved and an appropriate use of program resources. We randomly selected 25 of 2,355 non-payroll transactions as the basis for our testing. For one of the transactions, there was no evidence the expenditures had been reviewed and approved as appropriate expenditures for the program. The specific transaction was for cell phones and data plans on wireless devices and consisted of 584 separate devices. Only 24 (2.5%) of those devices had been approved by a manager. The department will pay the vendor for the full amount of the invoice. Managers are expected to review the charges for their unit and verify they are directed to the proper cost center. The $35,416 in questioned costs represents the charges for the devices without approval. Also, during fiscal year 2022, payroll for the department was processed through the Oregon State Payroll Application (OSPA). As part of each monthly payroll cycle, managers are expected to review and approve employee?s reported hours to ensure expenditures are accurate and are billed to the correct program(s). Although state policy requires managers to review the timesheets, the automated controls in the system will process the payroll without a review, effectively making the managerial review optional. The OSPA was retired as of November 30, 2022; however, the replacement payroll system operates in a similar manner for managerial review. As part of our testing of payroll expenditures, we found one of 25 randomly selected timesheets were not reviewed by a manager prior to release into the payroll system. We were able to perform alternative procedures to verify the amounts charged to the program were appropriate and there are no questioned costs. The lack of review increases the risk that inappropriate costs may be charged to federal programs. We recommend management ensure wireless device charges are properly reviewed, and expenditures are charged to the correct cost center or program. We also recommend management implement procedures to ensure all employee payroll submissions are reviewed and approved by program management. MANAGEMENT RESPONSE: We agree with this recommendation. The questioned costs related to cell phone charges appear to have resulted from a lack of formal process in the Coronavirus Response and Recovery Unit. This unit has closed and departments have returned to standardized formal processes. Corrective action plan: ? Prior to ?COVID-19? processes and procedures will be followed ? Administrative staff will parse cell phone charges and code invoices according to employee payroll ? Approving manager will review coding for accuracy prior to approval Anticipated Completion Date: January 1, 2023 Contact: Merry Carlson, ELC Contracts Manager

View Audit 45093 Questioned Costs: $1

Finding 47789 (2022-051)

Significant Deficiency 2022

State of Oregon

OR

Questioned Costs Cash Management Significant Deficiency § 200.302

2022-051 Oregon Health Authority Correct expenditures charged to the incorrect program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and ...

2022-051 Oregon Health Authority Correct expenditures charged to the incorrect program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK000541 (COVID-19) Compliance Requirements: Activities Allowed or Unallowed Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $356,050 (COVID-19) Criteria: 2 CFR 200.302 To address the COVID-19 pandemic, the Center for Disease Control (CDC) awarded the Oregon Health Authority (department) over $495 million in additional funding beyond the normal funding levels for the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) program. The funding was awarded for specific purposes such as enhancing detection, reopening schools, and enhancing detection expansion. The purposes of these awards generally do not allow for expenditures directly related to operating the COVID-19 vaccine clinics. In our testing, we identified two payments totaling $356,050 relating to emergency medical technicians attending vaccine clinics to assist if those receiving the vaccine had adverse reactions and required medical attention. Per department management, the transactions should have been charged to a different grant provided by the Federal Emergency Management Agency (FEMA). The error was caused by incorrect account coding when the invoice was processed. Other transactions under this contract were properly charged to the FEMA grant. We recommend management correct the accounting error and ensure the expenditures are charged to the correct programs. We also recommend the department determine if there are additional questioned costs relating to the advanced cash draw as the federal programs have different timing for federal reimbursements. MANAGEMENT RESPONSE: We agree with this recommendation. Corrective action plan: ? Adjust the two identified payments charged to the grant in error ? Adjust the erroneous charges to the Federal Emergency Management Agency (FEMA) grant ? Complete internal audit of expenditures and adjust any non-grant compliant expenditures out of this grant prior to federal financial reporting and close-out. Anticipated Completion Date: June 30, 2023 Contact: Kim Riddell, Program Support Coordinator and Jeff Cartwright, ACDP Lead Fiscal Analyst

View Audit 45093 Questioned Costs: $1

Finding 47787 (2022-045)

Significant Deficiency 2022

State of Oregon

OR

Subrecipient Monitoring Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

2022-045 Oregon Health Authority Submit required FFATA reports Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements; 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases; 93.958 Bloc...

2022-045 Oregon Health Authority Submit required FFATA reports Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements; 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases; 93.958 Block Grants for Community Mental Health Services; 93.959 Block Grants for Prevention and Treatment of Substance Abuse Federal Award Numbers and Years: 93.268: 5 NH23IP922626; 6 NH23IP922626; 93.323: 6 NU50CK000541; 93.958: 1B09SM083823, 2021; 93.959: 6B08TI083472, 2021; 6B08TI084667, 2022 Compliance Requirement: Reporting Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 170 Appendix A; 2 CFR 200.303 Federal regulations require recipients of federal awards to report certain subaward information in the FFATA Subaward Reporting System (FSRS) for subawards meeting the criteria for reporting. Reports must be submitted no later than the end of the month following the month in which the subawards were made. Federal regulations also require recipients of federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. We identified and reviewed the reporting status of all the department?s subawards subject to FFATA reporting during the audit period. We determined: Five of 30 Mental Health Block Grant (MHBG) subawards were not reported, totaling $4.2 million in obligations. 12 of 65 Substance Abuse Block Grant (SABG) subawards were not reported, totaling $6.2 million in obligations. Four of 37 Epidemiology and Laboratory Capacity (ELC) subawards were not reported, totaling almost $55.5 million in obligations. Five of 39 Immunization Cooperative Agreements subawards were not reported, totaling $6.3 million in obligations. Of the total not reported, one SABG, one ELC, and two Immunization subawards were not reported in the FSRS due to oversights in the department?s reporting process. The remaining unreported subawards resulted from the department?s suspension of FFATA reporting stemming from the federal replacement of the DUNS number with the Unique Entity Identifier (UEI) in May 2022. The department did not have UEI numbers for all subrecipients at the time of the replacement which prevented the department from submitting accurate reports. FFATA reporting was suspended through the end of state fiscal year 2022 and into the following state fiscal year. Although the department suspended FFATA reporting in the FSRS, a tracking spreadsheet was maintained that included all subaward award information needed for reporting once reporting is resumed. We recommend department management resume FFATA reporting as soon as feasible and ensure all necessary subawards are reported. We further recommend department management implement controls to ensure all subawards are appropriately tracked and reported. MANAGEMENT RESPONSE: We agree with this recommendation. On April 4, 2022, the federal government made a switch in the identifying information required for a subrecipient, changing from the previously used DUNS to a newly assigned Unique Entity Identifier (UEI). ODHS/OHA was not made aware of the upcoming federal switch until late March 2022. OHA?s Office of Contracts & Procurement (OC&P) is working directly with Program Contract Administrator?s to request the missing UEIs. As the data comes in from Program it is being validated for accuracy and updated in the appropriate systems, so when all missing UEIs from a given FAIN?s report month are collected, all NTE changes can be made immediately. OC&P is confident all FFATA reporting related to this audit will be submitted by July 31, 2023. Anticipated Completion Date: July 31, 2023 Contact: Brenda Brown, Procurement Manager

View Audit 45093

Finding 47786 (2022-050)

Significant Deficiency 2022

State of Oregon

OR

Allowable Costs / Cost Principles Significant Deficiency § 200.303

2022-050 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements (COVID-19) Federal Award Numbers and Years: 5 NH23IP922626, 2022 (COVID-1...

2022-050 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements (COVID-19) Federal Award Numbers and Years: 5 NH23IP922626, 2022 (COVID-19) 6 NH23IP922626, 2022 (COVID-19) Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Significant Deficiency Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.303 During fiscal year 2022, payroll for the Oregon Health Authority was processed through the Oregon State Payroll Application (OSPA). As part of each monthly payroll cycle, managers are expected to review and approve employee?s reported hours to ensure expenditures are accurate and are billed to the correct program(s). Although state policy requires managers to review the timesheets, the automated controls in the system will process the payroll without a review, effectively making the managerial review optional. The OSPA was retired as of November 30, 2022. However, the new Workday application that went into effect to replace the OSPA has the same weakness where payroll will process without regard for the managerial review. As part of our testing of program expenditures, we found that 3 of 134 timesheets were not reviewed by a manager prior to release into the payroll system. For each of these items, we were able to perform alternative procedures to verify that the amounts charged to the program were appropriate and there are no questioned costs. However, the lack of review increases the risk that inappropriate payroll costs may be charged to the program. We recommend management implement procedures to ensure that all employee payroll submissions are properly reviewed, and payroll is appropriately charged to the correct cost center or program. MANAGEMENT RESPONSE: We agree with this recommendation. The Oregon Immunization Program (OIP) section manager immediately notified all supervisory managers and administrative support staff of the finding on June 5th. Finding: ?As part of our testing of program expenditures, we found that 3 of 134 timesheets were not reviewed by a manager prior to release into the payroll system.? Supervisory managers were reminded that it is an expectation of their position to ensure that payroll time entries are thoroughly reviewed, and discrepancies resolved, and final entries approve according to agency requirements ? on time, every month. On June 5th, program administrative staff and the section manager began development of an internal standard operating procedure (SOP) that will thoroughly document the steps the program requires of supervisory managers to assure that all employee payroll submissions are properly reviewed and payroll is appropriately charged to the correct cost center or program. The final SOP will be signed by each supervisory manager in the program, and included in a quarterly Performance, Accountability and Feedback (PAF) session between each supervisory manager and the section manager. The final SOP will be delivered to the offices of the Secretary of State Audit Division, and DAS once approved by the Division management, and signed by each OIP supervisory manager. This finding and the resolution will be shared as well with our funder, the Centers for Disease Control and Prevention, as required by our cooperative agreement. Anticipated Completion Date: July 5, 2023 Contact: Mimi Luther, OIP Section Manager (interim)

View Audit 45093

Finding 47771 (2022-102)

Significant Deficiency 2022

Labors Community Service Agency

AZ

Reporting Special Tests & Provisions Significant Deficiency

Finding 2022 - 102 ? Improve the Timeliness of Filing the Annual Audit (Significant Deficiency) FAL Number: 14.239 Program Title: HOME Investment Partnership Program Condition and Context: LCSA?s single audit reporting package for the fiscal year ended June 30, 2022, was not submitted to the Fe...

Finding 2022 - 102 ? Improve the Timeliness of Filing the Annual Audit (Significant Deficiency) FAL Number: 14.239 Program Title: HOME Investment Partnership Program Condition and Context: LCSA?s single audit reporting package for the fiscal year ended June 30, 2022, was not submitted to the Federal Audit Clearinghouse by the required deadline of March 31, 2023. Recommendation: The auditors recommend that LCSA devote the necessary resources to the accounting function to meet its reporting obligations. Doing so will improve the timeliness of LCSA?s submittal to the Federal Audit Clearinghouse. Contact Name: Rebekah Friend, Executive Director Corrective Action Planned: Management is contracting with an outside accounting company to reconcile all accounting records on a monthly basis to allow the audits to be on time. Anticipated Completion Date: Immediately

View Audit 41448

Finding 47770 (2022-101)

Significant Deficiency 2022

Labors Community Service Agency

AZ

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

Finding 2022 - 101 ? Improve Home Inspection Process (Significant Deficiency) FAL Number: 14.239 Program Title: HOME Investment Partnership Program Condition and Context: LCSA did not properly document the procedures taken to inspect the homes maintained through their HOME program. Recommendati...

Finding 2022 - 101 ? Improve Home Inspection Process (Significant Deficiency) FAL Number: 14.239 Program Title: HOME Investment Partnership Program Condition and Context: LCSA did not properly document the procedures taken to inspect the homes maintained through their HOME program. Recommendation: The auditors recommend maintaining a list or memoranda including the items inspected at each home during routine inspections for documentation purposes. Contact Name: Rebekah Friend, Executive Director Corrective Action Planned: Management is creating a procedure and form to document the tracking of homes maintained. Anticipated Completion Date: Immediately

View Audit 41448

Finding 47741 (2022-002)

Significant Deficiency 2022

Ave Maria University, Inc. and Subsidiaries

FL

Eligibility Reporting Significant Deficiency § 200.328 § 200.329

Finding Number: 2022-002 Planned Corrective Action: The Business office has endeavored to keep pace with the shifting and changing guidance that is promulgated by the Department of Education. This ...

Finding Number: 2022-002 Planned Corrective Action: The Business office has endeavored to keep pace with the shifting and changing guidance that is promulgated by the Department of Education. This has been a challenge. The Chief Financial Officer continues to monitor any guidance updates and make the appropriate changes to the reports to ensure their accuracy. There was only one report posted that contained one typographical error, but it is the University?s responsibility to ensure the accuracy of the reports and these reports will be monitored more closely going forward. Anticipated Completion Date: Continuing Responsible Contact Person: Eugene L. Munin

View Audit 52869

Finding 47729 (2022-002)

Significant Deficiency 2022

Western States Information Network, Inc.

CA

Cash Management Reporting Significant Deficiency

WSIN concurs on finding 2022-002. To prevent further incidences, WSIN plans to revise its written accounting procedures to strengthen internal control policies on reporting program income. Greater emphasis will be taken to ensure the general ledger is updated in a timely manner, so program income is...

WSIN concurs on finding 2022-002. To prevent further incidences, WSIN plans to revise its written accounting procedures to strengthen internal control policies on reporting program income. Greater emphasis will be taken to ensure the general ledger is updated in a timely manner, so program income is reported on the federal financial quarterly reports based off the WSIN general ledger rather than a secondary tracking spreadsheet. WSIN management will ensure financial reporting has been through a secondary review prior to submission to US DOJ/OJP/BJA.

View Audit 52802

Finding 47712 (2022-003)

Significant Deficiency 2022

Municipality of Naranjito

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF NARANJITO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _________________________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Co...

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF NARANJITO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _________________________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2021 ? June 30, 2022 Fiscal Year: 2021-2022 Principal Executive: Hon. Orlando Ortiz Chevres - Mayor Contact Person: Mrs. Belinda Alvarez, Finance Director Phone: (787) 869 - 2200 Original Finding Number: 2022-003 Statement of Concurrence or Nonconcurrence: We concur with the finding. Corrective Action: The fiscal year 2021-2022 Single Audit submission for Municipality of Naranjito will be submitted through the Federal Audit Clearinghouse (FAC) no later than May 30, 2023. About the subsequent year Single Audit, we engaged the audit services on March 31, 2023, and we are going to engage the financial statements preparation consulting services on July 2023, in order to comply with fiscal year 2022-2023 Single Audit submission dateline. Implementation Date: During Fiscal Year 2023-2024. Responsible Person: Mrs. Belinda Alvarez - Finance Department Director See Corrective Action Plan for chart/table

View Audit 51135

Finding 47704 (2022-003)

Significant Deficiency 2022

Change Happens!

TX

Subrecipient Monitoring Reporting Significant Deficiency

Finding #2022-003 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01,...

Finding #2022-003 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 Condition and context: Change Happens did not file the required FFATA reporting for the 7 subawards over $30,000. Recommendation: Develop a process for FFATA reporting to ensure timely reporting for all federal programs, where applicable, and provide training to personnel regarding FFATA reporting requirements. Planned corrective action: A process for FFATA reporting will be finalized to ensure timely reporting of all federal programs. Policies and procedures will be updated to include this required reporting and the associated process. Staff training regarding FFATA reporting requirements will be provided to ensure the process is understood and properly implemented. Responsible officer: Angelica Castillo, CFO Estimated completion date: July 15, 2023

View Audit 47820

Finding 47675 (2022-002)

Significant Deficiency 2022

Network Housing 90, Inc.

OH

HUD Housing Programs Internal Control / Segregation of Duties Reporting

Finding Number: 2022-002 Condition: The Organization failed to make the required reserve for replacements deposits in the current fiscal year. Planned Corrective Action: Management agrees with the finding as reported. Management has instituted procedural changes to ensure that all required deposits ...

Finding Number: 2022-002 Condition: The Organization failed to make the required reserve for replacements deposits in the current fiscal year. Planned Corrective Action: Management agrees with the finding as reported. Management has instituted procedural changes to ensure that all required deposits are made monthly. Additionally, management has taken steps to deposit all delinquent deposits. Contact person responsible for corrective action: Paul Anderson, CFO Anticipated Completion Date: 12/31/2023

View Audit 41635

Finding 47670 (2022-001)

Significant Deficiency 2022

Walter Knox Memorial Hospital Doing Business As Valor Health

ID

Procurement, Suspension & Debarment Material Weakness Significant Deficiency

2022-001 Policies and Procedures for Federal Awards Corrective action planned: Create a written policy and procedure on the tracking and usage of federal awards and have it uploaded into our policy and procedure software. Anticipated completion date: February 28th, 2023 Contact person responsible ...

2022-001 Policies and Procedures for Federal Awards Corrective action planned: Create a written policy and procedure on the tracking and usage of federal awards and have it uploaded into our policy and procedure software. Anticipated completion date: February 28th, 2023 Contact person responsible for corrective action: Corey Furin, CFO

View Audit 52667

Finding 47667 (2022-002)

Significant Deficiency 2022

Housing Authority of Skagit County

WA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that a utility allowance review is performed annually. If waivers are requested, we recommend the Authority ensures the requested waivers are approved to ensure c...

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that a utility allowance review is performed annually. If waivers are requested, we recommend the Authority ensures the requested waivers are approved to ensure compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: If HUD waivers are available and applied for, the Section 8 Program Manager will confirm approval of the waiver before implementing the requested waiver. The waiver approval will be reviewed by the Section 8 Program Manager and co-signed by another manager at HASC. Name(s) of the contact person(s) responsible for corrective action: Cathy Kerr Planned completion date for corrective action plan: July 11, 2023

View Audit 52922

Finding 47666 (2022-001)

Significant Deficiency 2022

Housing Authority of Skagit County

WA

Questioned Costs HUD Housing Programs Significant Deficiency

2022-001 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that required HQS and QC inspections are completed timely. We recommend the Authority implements controls to ensure abatement is timely for units that do not corr...

2022-001 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that required HQS and QC inspections are completed timely. We recommend the Authority implements controls to ensure abatement is timely for units that do not correct the cited HQS deficiencies within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HQS Inspections-The Housing Authority of Skagit County (HASC) experienced HQS Inspector turnover during the COVID-19 pandemic. Since the pandemic, HASC hired a new HQS Inspector who has attended and completed HQS Inspector Certification. The inspector is scheduling and completing the inspections according to regulations, including timeliness. The Section 8 Program Manager will monitor the HQS Inspector. Quality Control (QC) Inspections-HASC applied for a waiver to not administer Quality Control Inspections during FY 2022, but HUD did not process the waiver request due to the volume of requests. HASC did not confirm the waiver was approved, which was an oversight. Please see below for corrective action regarding approval of waivers. For FY 2023, Quality Control Inspections have already been initiated. Failed Inspections-A spreadsheet has been created that will be utilized by the HQS Inspector and monitored by the Section 8 Program Manager. Each failed inspection will be added to the spreadsheet. The spreadsheet will document when the re-inspection is due and when HAP abatement is scheduled to take place. The spreadsheet will be reviewed on a weekly basis, by the Program Manager. This spreadsheet will increase inter-department communication and assist in following through with landlord communication and abatement when abatement is required. Name(s) of the contact person(s) responsible for corrective action: Cathy Kerr Planned completion date for corrective action plan: July 11, 2023

View Audit 52922 Questioned Costs: $1

Finding 47644 (2022-006)

Significant Deficiency 2022

South Adams Schools

IN

Equipment & Real Property Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303 § 200.313

CORRECTIVE ACTION PLAN FINDING 2022-006 Contact Person Responsible for Corrective Action: Heidi Sprunger Contact Phone Number: 260-589-3133 Views of Responsible Official: The district does not concur with this finding. The reason is as follows: According to the federal grant guidelines you must not ...

CORRECTIVE ACTION PLAN FINDING 2022-006 Contact Person Responsible for Corrective Action: Heidi Sprunger Contact Phone Number: 260-589-3133 Views of Responsible Official: The district does not concur with this finding. The reason is as follows: According to the federal grant guidelines you must not pay for any work, services, or products on a project until the work is completed. The $1,685,526 is what was completed within the timeframe of the audit. Asset Control company is who the district uses to complete their capital asset listing every 2 years. At the time of the visit Asset Control was made aware of our project. They had requested that we provide them with the entire project cost. Asset Control wanted to include the full price for insurance coverage because the project would still be ongoing. The district provided documentation of the invoices paid during the audit period to show the amount of the project was paid for federal grant funds at the time of the audit period. Description of Corrective Action Plan: The district has no corrective action plan because the project is now completed and Asset Control company has the full cost of the project list within our assets. Anticipated Completion Date: Immediately

View Audit 48846

Finding 47603 (2022-003)

Significant Deficiency 2022

Morningstar Children and Family Services, Inc.

GA

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2022-003 Condition: Supporting documentation was missing for 3 of 40 disbursements selected for allowable cost testing. Cause: Internal controls did not provide for supporting documentation to be adequately retained. Recommendation: Internal control procedures on recordkeeping and filing...

Finding 2022-003 Condition: Supporting documentation was missing for 3 of 40 disbursements selected for allowable cost testing. Cause: Internal controls did not provide for supporting documentation to be adequately retained. Recommendation: Internal control procedures on recordkeeping and filing should be clearly stated as part of the Organizational policy. Management Response: We concur with the finding. The receipts, with a total value less than $200 could not be located during the audit. Corrective Actions: 1. Actions have been taken to diminish the use of the company credit card for purchases. 2. Beginning March 2023, an enterprise level application was deployed to track and automate the collection of expenses and receipts for approved users. 3. The accounting department has set up additional direct bill accounts for improved ordering processes and less frequent use of credit cards and subsequent receipt retention requirements. Name of Responsible Person: Beth VanDerbeck

View Audit 41687

Finding 47598 (2022-001)

Significant Deficiency 2022

City of Haverhill

MA

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Education The City of Haverhill, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Powers & Sullivan, LLC 10...

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Education The City of Haverhill, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 Audit period: July 1, 2021 through June 30, 2022 The finding from the June 30, 2022, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. DEPARTMENT OF EDUCATION Passed through the Massachusetts Department of Elementary and Secondary Education Title I Grants to Local Educational Agencies Title I Grants to Local Educational Agencies Federal Assistance Listing No. 84.010 Special Education Cluster Special Education Grants to States and Special Education Preschool Grants Federal Assistance Listing Numbers, 84.027 and 84.173. 2022-001: Controls for Monitoring Payroll Charged to the Grant Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Compliance and Significant Deficiency in Internal Control over Compliance Criteria or Specific Requirement: Grantees must provide reasonable assurance that Federal awards are expended only for allowable activities and that the costs of goods and services charged to Federal awards are allowable and in accordance with the applicable cost principles. Condition: Management has not established written guidelines and procedures outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Such guidelines and procedures should indicate under what circumstances semi-annual certifications and personnel activity reports (PARS) are required and should indicate due dates for when this information must be provided to the school business office. Management also has not adopted and implemented standardized forms for semi-annual certifications and PARS that include all data required by federal and state guidelines. Questioned Costs: None reported. Context: Payroll expenditures charged to the programs are required to be supported with documentation substantiating that the employees are eligible to be charged to the grant and that the payroll charged relates to time spent accomplishing grant objectives. This supporting documentation should be standardized and should include all required elements in accordance with Title 2 U.S. Code of Federal Regulations Part 225 Cost Principals for State, Local, and Indian Tribal Governments. The City did not have an adequate system of internal controls in place to provide sufficient documentation to demonstrate compliance with federal and state time and effort reporting requirements in accordance with the provisions of Title 2 U.S. Code of Federal Regulations Part 225 Cost Principals for State, Local, and Indian Tribal Governments. Effect: The City has not complied with the federal and state time and effort reporting requirements. Cause: Lack of documented policies, procedures and guidelines in place to ensure compliance with time and effort reporting requirements. Repeat Finding: This matter was reported as a finding for the special education cluster grants in the previous year as finding 2021-004. Recommendation: Management should establish written guidelines and procedures outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Such guidelines and procedures should indicate under what circumstances semi-annual certifications and personnel activity reports (PARS) are required and should indicate due dates for when this information must be provided to the school business office. Management should also adopt and implement standardized forms for semi-annual certifications and PARS that include all data required by federal and state guidelines. Once the written guidelines and procedures have been established, training should be provided to ensure that the program managers fully understand the time and effort reporting requirements. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will establish written guidelines and procedures outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Such guidelines and procedures will indicate under what circumstances semi-annual certifications and personnel activity reports (PARS) are required and will indicate due dates for when this information must be provided to the school business office. Management will also adopt and implement standardized forms for semi-annual certifications and PARS that include all data required by federal and state guidelines. Once the written guidelines and procedures have been established, training will be provided to ensure that the program managers fully understand the time and effort reporting requirements. Management intends to implement these procedures in fiscal 2023. If the Oversight Agency has questions regarding this plan, please call Michael Pfifferling, Assistant Superintendent of Finance and Operations at 978-374-3400. Sincerely yours, Michael Pfifferling Assistant Superintendent of Finance and Operations City of Haverhill

View Audit 52314

Finding 47556 (2022-003)

Significant Deficiency 2022

The Jewish Theological Seminary of America

NY

Cash Management Significant Deficiency

Finding 2022-003: Cash Management Recommendation: We recommend that the Seminary add additional procedures to ensure that they are complying with cash management requirements. ...

Finding 2022-003: Cash Management Recommendation: We recommend that the Seminary add additional procedures to ensure that they are complying with cash management requirements. Action Taken/Underway: Effective September 2022, management has implemented procedures, including timely draws and disbursements, to ensure the Seminary is complying with cash management requirements.

View Audit 41629

Finding 47555 (2022-002)

Significant Deficiency 2022

The Jewish Theological Seminary of America

NY

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

Finding 2022-002: Borrower Data and Reconciliation Recommendation: We recommend that the Seminary add additional procedures to ensure that they are performing and maintaining monthly ...

Finding 2022-002: Borrower Data and Reconciliation Recommendation: We recommend that the Seminary add additional procedures to ensure that they are performing and maintaining monthly School Account Statement reconciliations. Action Taken/Underway: Effective September 2022, management has implemented procedures to ensure School Account Statement reconciliations are performed monthly and properly maintained.

View Audit 41629

Finding 47551 (2022-005)

Significant Deficiency 2022

Pennsylvania College of Art & Design

PA

Cash Management Significant Deficiency

A control has been added to verify all information in G5 during future reconciliation processes.

View Audit 45767

Finding 47550 (2022-004)

Significant Deficiency 2022

Pennsylvania College of Art & Design

PA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

A control has been added to ensure that staff with reporting compliance responsibilities are appropriately trained prior to award execution and during periods of transition.

View Audit 45767

Finding 47549 (2022-003)

Significant Deficiency 2022

Pennsylvania College of Art & Design

PA

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

The College agrees with this recommendation and will add procedures to confirm that student consents are included in their respective files.

View Audit 45767

Corrective Action Plans

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