Corrective Action Plans

Finding 32430 (2022-010)

Significant Deficiency 2022

PA

Reporting School Nutrition Programs Equipment & Real Property Management

IT - PDA?s PA Meals team will incorporate appropriate migration strategies within the policy of ITP_INF000, along with providing a migration audit plan checklist for any future data migrations. Additionally, the INF000 will be incorporated into the Delivery Center?s development framework, where a...

IT - PDA?s PA Meals team will incorporate appropriate migration strategies within the policy of ITP_INF000, along with providing a migration audit plan checklist for any future data migrations. Additionally, the INF000 will be incorporated into the Delivery Center?s development framework, where appropriate. PDA added a Business Analyst to the team for assisting with future application testing and documentation. This individual will be directly involved in helping develop and orchestrate a testing strategy based on delivery center standards to include, but not limited to: - Determine appropriate criteria to be tested. - Assist in establishing a test group of qualified testers. - Coordinate with technical team on pass/fail criteria. - Utilize standard testing tasks/checklists ensuring consistency. - Assist the team, key business users and the technical team in reviewing testing results. The reports were reviewed electronically (100s of report pages) checking for various scenarios. As a result, these complete reports are similar and difficult to distinguish between without an associated checklist and specific report criteria. In the future, full test plans and execution results capturing pass/fail of the defined tests will be retained in pdf (or similar) format. The team will continue with best practices and delivery center standards, utilizing a Business Analyst as part of the testing and review process. The SEFA report had extensive testing, however, there is a timing issue that will always exist if the expectation is to provide the data in both January and September. The January report will be accurate for when it is run, along with what transactions were sent by the warehouse vendor. Subsequently, changes can and will occur to those commodities being reported on over the next 6 months. Additionally, it is reliant upon the warehouse vendor to report all transactions timely. As a result, running the same report after June 30th will consistently vary due to a physical inventory review in June, along with additional transactions being updated as part of the inventory review. PDA is recommending a one-time annual report in September, which will include all the adjustments from a June physical inventory and updated transactions. A January report is fine to run but should not be considered a fully accurate assessment due to the timing and missing data. Program - PDA strives to maintain accurate and complete records with respect to the receipt, distribution, and inventory of USDA donated foods, including end products processed from donated food. To that end, PDA has already or will put the following steps in place to strengthen procedures for future periods to ensure errors identified during the reconciliation process are corrected timely in the system: 1) All findings noted with regards to the Commodity Processors Inventory Report have been corrected and no known issues remain. 2) No further inventory balances remain on record with inactive distributors, as all product was previously transferred to active distributors. 3) Processor monthly performance reports (MPRs) will be completed and filed in accordance with USDA?s prescribed schedule (90 days after completion of month). 4) BFA will work with the Commodity Distributors and USDA to mutually resolve discrepancies and achieve reconciliation with USDA receipts. 5) Moving forward, all Commodity Distributor Inventory Reports will be reconciled by the beginning of a new federal fiscal year (October 1), and inventory balances at commodity distributors will agree with year-end physical inventory counts. Anticipated Completion Date: IT - 09/30/2023; Program 1-Completed; 2-Completed; 3-09/30/2023; 4-09/30/2023; 5-09/30/2023 Contact Person and Title: Caryn Long Earl, PDA, Director, Bureau of Food Assistance (BFA)

View Audit 27724

Finding 32425 (2022-001)

Significant Deficiency 2022

Area Xv Multi-County Housing Agency

IA

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

The Authority recognizes that the utility schedule was not updated in the most recent fiscal year. There has been staff turnover in the Authority in the roles that have oversight over these policies and in the transition, numerous things were not communicated as to whose responsibility it now is. Th...

The Authority recognizes that the utility schedule was not updated in the most recent fiscal year. There has been staff turnover in the Authority in the roles that have oversight over these policies and in the transition, numerous things were not communicated as to whose responsibility it now is. The Executive Director will be contacting HUD to determine the next course of action as the utility allowance schedule has been updated for 2023.

View Audit 27901

Finding 32418 (2022-003)

Significant Deficiency 2022

Crawford County Community School Corporation

IN

Subrecipient Monitoring Reporting Significant Deficiency § 200.302 § 200.303 § 200.328

Finding 2022-003 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Departmen...

Finding 2022-003 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards and the GEER grant award. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. We noted for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. Crawford County Community School Corporation will continue submission of required data to the IDOE on federal spending with at least two people completing the curation. However, final drafts will be reviewed and then final reports will be signed by the at least two people who reviewed the final draft. This signed copy, if not required to be submitting to the IDOE, will be kept locally. Responsible party and timeline for completion: 1) Amy Belcher, Program Administrator, will ensure all final reports have been reviewed and signed by at least two people before submission to the IDOE immediately.

View Audit 27913

Finding 32416 (2022-001)

Significant Deficiency 2022

Food Gatherers, Inc.

MI

School Nutrition Programs Significant Deficiency Equipment & Real Property Management

Management has identified the incident where an agency signature was not obtained upon delivery of USDA foods to that agency. Management has verified that the delivery of USDA foods to that agency was a legitimate delivery in accordance the Compliance Requirements for the Emergency Food Assistance ...

Management has identified the incident where an agency signature was not obtained upon delivery of USDA foods to that agency. Management has verified that the delivery of USDA foods to that agency was a legitimate delivery in accordance the Compliance Requirements for the Emergency Food Assistance Program. Management believes that enhanced training and supervision will improve the application of management's documented controls that require agency signatures be obtained upon delivery of USDA foods to partnering agencies.

View Audit 27798

Finding 32393 (2022-003)

Significant Deficiency 2022

Cabrini University

PA

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

2022-003 Student Financial Assistance Cluster ? Assistance Listing No. 84.038 Recommendation: We recommend the University evaluate its procedures around the retention of Perkins loans r...

2022-003 Student Financial Assistance Cluster ? Assistance Listing No. 84.038 Recommendation: We recommend the University evaluate its procedures around the retention of Perkins loans records to ensure that all records for open loans are being properly maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will continue to identify open loan records with missing master promissory notes. As such loan records are identified, the University will take necessary measures to request permission to assign these loans to the Department of Education. As this work is ongoing, all current loan records will continue to be stored securely in the Bursar?s area. Name(s) of the contact person(s) responsible for corrective action: Rita Lambert, Bursar Planned completion date for corrective action plan: August 31, 2023

View Audit 27062

Finding 32392 (2022-004)

Significant Deficiency 2022

Cabrini University

PA

Questioned Costs Student Financial Aid Significant Deficiency

2022-004 Student Financial Assistance Cluster ? Assistance Listing No. 84.268 Recommendation: We recommend the University review all R2T4 calculations to ensure the correct net disbur...

2022-004 Student Financial Assistance Cluster ? Assistance Listing No. 84.268 Recommendation: We recommend the University review all R2T4 calculations to ensure the correct net disbursed amounts are entered for all Title IV aid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Financial Aid will recalculate the R2T4 with the correct net disbursement amount and request the additional funding directly through COD. Going forward, the Office of Financial Aid will perform a secondary review of all R2T4 calculations prior to processing for accuracy. Name(s) of the contact person(s) responsible for corrective action: Robert Forest, Director of Financial Aid Planned completion date for corrective action plan: March 30, 2023

View Audit 27062 Questioned Costs: $1

Finding 32391 (2022-002)

Significant Deficiency 2022

Cabrini University

PA

Reporting Student Financial Aid Significant Deficiency

2022-002 Student Financial Assistance Cluster ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University review its policies and procedures to ensure accurate e...

2022-002 Student Financial Assistance Cluster ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University review its policies and procedures to ensure accurate effective dates are reported in both the campus and program level records submitted to the NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar?s Office will review National Student Clearinghouse (NSC) information following transmission, particularly for effective dates of completely withdrawn students. The NSC reports enrollments to NSLDS for the University. Name(s) of the contact person(s) responsible for corrective action: Gerard J. Donahue, Registrar Planned completion date for corrective action plan: June 30, 2023

View Audit 27062

Finding 32355 (2022-001)

Significant Deficiency 2022

Thomas Health System, Inc.

WV

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-001 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Criteria: All recipients of Provider Relief Funds (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions an...

Finding 2022-001 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Criteria: All recipients of Provider Relief Funds (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions and specified in directions issued by the U.S. Department of Health and Human Services. Condition and Context: The System did not complete the PRF reporting for Period 2 in accordance with the U.S. Department of Health and Human Services guidance due to errors in the underlying data that lead to errors in the Period 2 report that was submitted. In the period 2 Submission, the System reported $2,283,650 of COVID-19 expenses, but failed to reduce the expenses by amounts reimbursed by other sources. Management updated their policies and procedures prior to Reporting Period 3 to address this issue. The System had $42,620,438 of lost revenue through Period 2 reporting, and has received $17,690,624 in PRF payments. Corrective Action Plan Corrective Action Planned: Thomas Health System, Inc. and its subsidiaries agrees with the finding, and policy and procedures were updated before reporting Period 3. Period 3 and 4 reporting were completed in accordance with the U.S. Department of Health and Human Services most guidance. The System received a notice from the Department of Health & Human Services dated December 29, 2022 that HRSA's Division of Financial Integrity has determined that the findings cited in the Single Audit Report for fiscal year October 1, 2020 through September 30, 2021 has been satisfactorily resolved. Name of Contact Person Responsible for Corrective Action: Timothy Skeldon, Chief Financial Officer, 4605 MacCorkle Ave SW, South Charleston, WV 25309 Anticipated Completion Date: Completed September 30, 2022

View Audit 28447

Finding 32351 (2022-004)

Significant Deficiency 2022

Spooner Health System

WI

Questioned Costs Allowable Costs / Cost Principles Cash Management

2022-004 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines and tie back to support. Explanation of disagreement with audit findi...

2022-004 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines and tie back to support. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The System will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. However, it is noted that there was sufficient lost revenue to support the PRF distributions received. Name(s) of the contact person(s) responsible for corrective action: Rebecca Busch, CFO Planned completion date for corrective action plan: We look to HRSA for guidance on how to correct the Period 1 report or will correct the error in a future reporting period. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Rebecca Busch, CFO at 715-939-1732.

View Audit 27255 Questioned Costs: $1

Finding 32335 (2022-001)

Significant Deficiency 2022

Hopeworks of Howard County, Inc.

MD

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Finding: Thirteen reports within three quarters were submitted after the required deadline. We recommend reviewing the controls in place to ensure that all future reports are submitted on time and in accordance with grant requirements. If the Organization expects that there will be a delay in the su...

Finding: Thirteen reports within three quarters were submitted after the required deadline. We recommend reviewing the controls in place to ensure that all future reports are submitted on time and in accordance with grant requirements. If the Organization expects that there will be a delay in the submission of the reports, they should obtain permission to extend the submission date from the awarding agency. Statement of Concurrence or Non-Concurrence Statement of Concurrence: HopeWorks concurs with the finding and recommendation listed above. Corrective Action HopeWorks has implemented a number of streamlined processes in which to expedite the availablity of information needed to file the funder reports more timely. These processes are not limited to electronic import of payroll and benefit entries, implementation and consistent use of Bill.com for expenditures, and prioritization of recording credit card activity. Fifteen days is a strict deadline and if for some reason reporting will be late, HopeWorks will communicate to the funder and document that communication. In FY23, we are also working to streamline the technology and our internal and departmental grant reporting processes to ensure that we are being as efficient as possible with our existing resources, both technological and human.

View Audit 27429

Finding 32303 (2022-004)

Significant Deficiency 2022

City of Nashwauk

MN

Internal Control / Segregation of Duties Significant Deficiency Subrecipient Monitoring

REPRESENTATION OF CITY OF NASHWAUK CORRECTIVE ACTION PLAN Year Ended December 31, 2022 Finding Number: 2022-004 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Correcti...

REPRESENTATION OF CITY OF NASHWAUK CORRECTIVE ACTION PLAN Year Ended December 31, 2022 Finding Number: 2022-004 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action April Kurtock, Clerk/Treasurer Corrective Action Planned The City Council will attempt to monitor transactions and structure the duties of office personnel to help ensure as much segregation of duties as possible within the City's staffing limitations and funding constraints Anticipated Completion Date Ongoing.

View Audit 31098

Finding 32302 (2022-001)

Significant Deficiency 2022

City of Chicopee, Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2022-001 Significant Deficiency in Internal Control Over Compliance ? U.S. Department of Treasury ? Coronavirus Relief Fund City Municipal Assistance ? (CFDA No. 21.019) ? Reporting (continued) Passed Through Commonwealth of Massachusetts Executive Office of Administration and Finance Nam...

Finding 2022-001 Significant Deficiency in Internal Control Over Compliance ? U.S. Department of Treasury ? Coronavirus Relief Fund City Municipal Assistance ? (CFDA No. 21.019) ? Reporting (continued) Passed Through Commonwealth of Massachusetts Executive Office of Administration and Finance Name of Person Responsible: Marie T. Laflamme, Treasurer Sharyn Riley, Auditor John Miarecki, School Director of Budget & Finance Corrective Action Planned: The City will immediately review all expenses related to the Coronavirus Relief Funds. The City will take steps to reconcile the Coronavirus Report to our General Ledger. Anticipated Completion Date: May 30, 2023

View Audit 31097

Finding 32238 (2022-001)

Significant Deficiency 2022

Village Cooperative of the Northland

MO

Internal Control / Segregation of Duties Significant Deficiency

The Board of Directors is and will remain involved in the financial affairs of the Cooperative.

View Audit 35774

Finding 32237 (2022-003)

Significant Deficiency 2022

Heal the Hero Foundation

AZ

Internal Control / Segregation of Duties Cash Management Significant Deficiency § 200.303

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization implement policies and procedures surrounding the cash disbursement process that ensures disbursements to the chief executive officer are reviewed and approved by a se...

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend that the Organization implement policies and procedures surrounding the cash disbursement process that ensures disbursements to the chief executive officer are reviewed and approved by a second, independent individual such as a board member. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement policies and procedures surrounding cash disbursement process ensuring disbursements to the chief executive officer are reviewed and approved by a second, independent individual such as a board member. Name(s) of the contact person(s) responsible for corrective action: Joseph Holmes Planned completion date for corrective action plan: 10/31/23

View Audit 34813

Finding 32212 (2022-011)

Significant Deficiency 2022

The Boulevard of Chicago, Inc.

IL

Allowable Costs / Cost Principles Cash Management Significant Deficiency

Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. All vouchers will be reviewed and approved by upper management before submission. These vouchers will be checked against a modified policy ensuring costs are reasonable, allowable, and all...

Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. All vouchers will be reviewed and approved by upper management before submission. These vouchers will be checked against a modified policy ensuring costs are reasonable, allowable, and allocable to a State, Federal, local, and private awards shall be charged to that award directly or indirectly. Name(s) of the contact person(s) responsible for corrective action: Shanan Egger, Chief Financial Officer Planned completion date for corrective action plan: September 2023

View Audit 31477

Finding 32166 (2022-004)

Significant Deficiency 2022

City of Richmond

VA

Student Financial Aid Eligibility Significant Deficiency

2022-Single Audit 01 Department of Social Services Title IV-E Adoption Assistance A sample of 40 children that received Title IV-E adoption subsidies during FY2022 was tested for compliance with the above criteria and the observations were noted below. ? 40 out of 40 children - Met the eligibilit...

2022-Single Audit 01 Department of Social Services Title IV-E Adoption Assistance A sample of 40 children that received Title IV-E adoption subsidies during FY2022 was tested for compliance with the above criteria and the observations were noted below. ? 40 out of 40 children - Met the eligibility requirements, had special needs that prevented them from being placed without a subsidy, and could not return home. ? 40 out of 40 children - RDSS made reasonable efforts to place the children without the subsidy or waived the requirement as it was not in the best interest of the child. ? 40 out of 40 children ? The adoption assistance agreements were signed prior to the final adoption decree, the authorized amounts were in line with the State?s rates, and payments were issued in accordance with the agreements. ? 9 out of 40 children ? Sufficient evidence of the completion of the required criminal background and child abuse and neglect registry checks for the adoptive parents and adult household members was not in the adoption case files. The home studies and report of investigations narrative indicated the required checks were completed for the adoptive parents and household members but did not identify when they occurred. Also, in some cases, it was not noted if the adoptive parents met the eligibility requirements for the criminal record checks. As such, the auditors were unable to confirm when the checks occurred, and supporting documentation was not provided prior to the completion of fieldwork. In addition, during the initial file review, documents such as court orders, negotiation documents, and annual affidavits were missing from some of the files. The Adoption Unit was ultimately able to retrieve and provide the missing items. However, an opportunity exists to improve the adoption case file documentation. Recommendations: ? We recommend that the Children, Families, and Adults (CFA) Deputy Director develop and implement a quality control process to ensure that the required documentation is maintained in the adoption case files. ? We recommend that the CFA Deputy Director develop and implement standard documentation requirements for documenting the completion of the background checks in the adoption case files. Explanation of disagreement with audit finding: n/a ? no disagreement Action planned/taken in response to finding: Audit Recommendation: We recommend that the Children, Families, and Adults (CFA) Deputy Director develop and implement a quality control process to ensure that the required documentation is maintained in the adoption case files. RDSS Corrective Action Plan: The Reunification and Permanency Program Manager or designee will conduct quarterly adoption case reviews using the VDSS Guidance Section 3.9.3 - Adoption Records. The quarterly case sample represents 10% of the case and all cases will be reviewed at least once annually. Any findings will be documented to include corrective actions, person responsible and timeframe for correction. The Reunification and Permanency Program Manager or designee will review cases to confirm corrections. Audit Recommendation: We recommend that the CFA Deputy Director develop and implement standard documentation requirements for documenting the completion of the background checks in the adoption case files. RDSS Corrective Action Plan: All RDSS Adoptions files must include the VDSS Adoption File Checklist and the child?s adoptive family documentation. The required adoptive parent documentation includes: o Criminal Background Check Results - Licensed Child Placing Agencies ( Non-Conviction and/or Conviction Letter); Local Department of Social Services (Office of Background Investigations Determination Letter) o Sworn Statement of Affirmation o Child Abuse and Neglect Central Registry Check results for adoptive parent and adult household members. The Adoption and Resource Families Supervisors are responsible for monitoring compliance with documentation requirements for completion of the background checks, including insuring that documentation is requested from child ?placing agencies and third parties. Standard documentation requirements regarding background checks will be included in the quarterly review by the Reunification and Permanency Program Manager or designee. Name(s) of the contact person(s) responsible for corrective action: Brinette Jones, Deputy Director, Division Children, Families and Adults Lavinia Hopkins, Reunification and Permanency Program Manger Planned completion date for corrective action plan: Ongoing, beginning 2nd quarter 2023 If there are any questions regarding this plan, please contact Brinette Jones at (804) 646-4543.

View Audit 35530

Finding 32163 (2022-005)

Significant Deficiency 2022

City of Richmond

VA

Eligibility Significant Deficiency Internal Control / Segregation of Duties

2022-Single Audit 02 Department of Social Services TANF Eligibility A sample of 40 FY2022 TANF cases was tested for compliance with the above criteria and the observations were noted below. ? 24 out of 40 cases files tested did not contain adequate documentation to verify eligibility requirements...

2022-Single Audit 02 Department of Social Services TANF Eligibility A sample of 40 FY2022 TANF cases was tested for compliance with the above criteria and the observations were noted below. ? 24 out of 40 cases files tested did not contain adequate documentation to verify eligibility requirements and approval of benefits. Approximately, 55% of the reviewed files lacked evidence that the workers verified the relationship between the minor children and the applicant and that the children were living in the home. ? 1 out of 40 case files tested, the assistance unit captured a child that was not living in the household, which inappropriately increased the monthly benefit amount. ? 1 out of the 40 cases tested did not contain evidence that the eligibility worker inquired about the applicant?s indication on the application that they were not in compliance with probation/sentencing terms prior to approving the application. Recommendations: ? We recommend that the Economic Support and Independence Deputy Director develop and implement a quality control process to ensure the required eligibility verifications are conducted and properly documented in the case files. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action planned/taken in response to finding: All supervisors within the Economic Support & Independence Division of the Richmond Department of Social Services (RDSS) will be expected to complete a minimum of three case readings per month for each direct report assessing eligibility within the TANF program. In addition, all team members who assess TANF eligibility will be required to complete refresher trainings on uploading documents to the Document Management Imaging System (DMIS), Documentation and Verifications, and Application Processing, which will include categorical requirements and conditions of eligibility. Name(s) of the contact person(s) responsible for corrective action: Sarah Raring & Tricia Wyatt Planned completion date for corrective action plan: June 30, 2023 If there are any questions regarding this plan, please contact Sarah Raring at (804) 646-3332 or sarah.denhamraring@rva.gov.

View Audit 35530

Finding 32145 (2022-002)

Significant Deficiency 2022

College of Mount Saint Vincent

NY

Student Financial Aid Special Tests & Provisions Eligibility

In regard to the two students who were never reported as graduated, the College did in fact submit the required documentation to the National Student Clearinghouse (?NSC?) for further processing to the NSLDS, but the updates were reported as rejected due to errors by the NSLDS. The College has updat...

In regard to the two students who were never reported as graduated, the College did in fact submit the required documentation to the National Student Clearinghouse (?NSC?) for further processing to the NSLDS, but the updates were reported as rejected due to errors by the NSLDS. The College has updated the students' records on the NSC and will monitor the NSLDS portal weekly to ensure that all student updates are processed and correct on both the campus and program levels. In regard to the publication of the length of the Master?s level program, the College is revising its documentation and publication of the length of the Master?s program to reflect adjustments to the program that reduced the amount of time needed to complete the program. In addition, the College?s student information system was reviewed/updated to accurately reflect the published length for each program. To assure that the information is being transmitted correctly, the College will monitor the next six months of enrollment updates to ensure that each student, in the different programs, has the correct publication program length.

View Audit 31463

Finding 32144 (2022-001)

Significant Deficiency 2022

College of Mount Saint Vincent

NY

Student Financial Aid Reporting Significant Deficiency

The College reviewed and updated the effectiveness of its procedures governing the reporting of Federal Direct Loan and Pell Grant disbursements to COD no later than 15 days after disbursements to students. The College is reporting the disbursements to COD within the 15-day timeframe to allow for mo...

The College reviewed and updated the effectiveness of its procedures governing the reporting of Federal Direct Loan and Pell Grant disbursements to COD no later than 15 days after disbursements to students. The College is reporting the disbursements to COD within the 15-day timeframe to allow for more timely drawdowns of federal funds. Those measures were and continue to be to extract and submit reporting to COD on a minimum weekly basis (with a goal of daily) to remain within the 15-day reporting requirement. Between the 2021-2022 aid years, the College?s Financial Aid department has experienced the leadership transition of three directors, and our current Director is identifying and implementing process refinements to previous steps taken to further improve internal controls. Further, the College has taken steps to both continue and enhance ongoing staff professional development sessions and training. In addition, the College contracted a Financial Aid consultant in the Fall of 2022 for an assessment of our system configurations and processes. The consultant has been retained to undertake a quarterly review of our setups and processes and assist in training the team. In accordance with best practices, Financial Aid?s goal is to continue to eliminate such errors. The findings continue to be addressed.

View Audit 31463

Finding 32088 (2022-004)

Significant Deficiency 2022

Southern Maryland Tri-County Community Action Committee, Inc.

MD

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding Reference: 2022-004 Federal Agency: Department of Treasury Compliance Requirement: Activities Allowed, Allowable Costs (Non-Payroll) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: ...

Finding Reference: 2022-004 Federal Agency: Department of Treasury Compliance Requirement: Activities Allowed, Allowable Costs (Non-Payroll) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: 21.023 ? Emergency Rental Assistance Grant Award: ERAPI Charles County Condition/Context: SMTCCAC was unable to provide documentation to support review and approval for one (1) of the 40 transactions selected for testing. Criteria: Internal Control: Per 2 CFR section 200.303(a), 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. These internal controls should comply with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Cause: SMTCCAC was unable to locate the Expenditure Request Form that demonstrates the approval of an invoice. Effect: The risk of unallowed costs increases due to lack of supervisor review and approval of expenditures charged to the program. Questioned Costs: None Recommendation: We recommend that SMTCCAC maintain the documentation of review and approval of expenditures charged to the federal award programs. Views of Responsible Officials and Planned Corrective Actions: See Corrective Action Plans section.

View Audit 32240

Finding 32087 (2022-003)

Significant Deficiency 2022

Southern Maryland Tri-County Community Action Committee, Inc.

MD

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

Finding Reference: 2022-003 Federal Agency: Department of Treasury Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: 21.023 ? Emergency Rental Assistanc...

Finding Reference: 2022-003 Federal Agency: Department of Treasury Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: 21.023 ? Emergency Rental Assistance Grant Award: ERAPI Charles County Condition/Context: SMTCCAC did not provide proof of review of the shared document among participating ERAP agencies in Charles County to avoid duplication of benefits for four (4) of the 60 rental assistance claims selected for testing. Criteria: Internal Control: Per 2 CFR section 200.303(a), 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. These internal controls should comply with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Cause: SMTCCAC did not adequately monitor controls to ensure proper review of the shared document among participating ERAP agencies in Charles County resulting in the potential duplication of benefits. Effect: Failure to review the shared document used among participating ERAP agencies in Charles County could result in duplication of benefits. Questioned Costs: None Recommendation: We recommend that SMTCCAC consistently verify the shared document used among participating ERAP agencies in Charles County to avoid duplication of benefits. Views of Responsible Officials and Planned Corrective Actions: See Corrective Action Plans section.

View Audit 32240

Finding 32086 (2022-002)

Significant Deficiency 2022

Southern Maryland Tri-County Community Action Committee, Inc.

MD

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Finding Reference: 2022-002 Federal Agency: Department of Treasury Compliance Requirement: Allowable Costs (Non-Payroll) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: 21.023...

Finding Reference: 2022-002 Federal Agency: Department of Treasury Compliance Requirement: Allowable Costs (Non-Payroll) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: 21.023 ? Emergency Rental Assistance Grant Award: ERAP I Charles County Condition/Context: FSTA selected a sample of sixty disbursements of rental assistance claims for testing and noted the following errors: ? SMTCCAC mistakenly processed a duplicate payment of $7,700 for an eligible claim, which was one (1) of the 60 rental assistance claims selected for testing in Charles County ERAP I grant. ? SMTCCAC made a payment of $31,800 to a landlord for one (1) of the 60 rental assistance claims selected for testing, for which another agency had made a payment for the same claim before SMTCCAC. Criteria: Internal Control: Per 2 CFR section 200.303(a), 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. These internal controls should comply with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Compliance: Under OMB guidance, Public Law (Pub. L.) No. 107-300, the Improper Payments Information Act of 2002, as amended by Pub. L. No. 111-204, the Improper Payments Elimination and Recovery Act, Executive Order 13520 on reducing improper payments, and the June 18, 2010 Memorandum on Enhancing Payment Accuracy - Any payment that should not have been made or that was made in an incorrect amount, including an overpayment or underpayment, under a statutory, contractual, administrative, or other legally applicable requirement; and includes ? (i) any payment to an ineligible recipient;(ii) any payment for an ineligible good or service; (iii) any duplicate payment; (iv) any payment for services not received; and (v) any payment that does not account for credit for applicable discounts. Cause: Due to staff turnover, the claim of $7,700 was submitted to Finance for payment twice. SMTCCAC did not sufficiently monitor controls to detect the duplicate payment. Additionally, SMTCCAC did not adequately monitor controls to ensure proper review of the shared document among participating ERAP agencies in Charles County to avoid the duplication of benefits for the claim of $31,800. Effect: The duplicate expenditure included in the program cost was deemed unallowable. The landlord involved in the rental assistance claim confirmed receiving two checks, each totaling $7,700. SMTCCAC did not require the landlord to return the duplicate funds, nor did it establish a repayment plan after the landlord expressed a willingness to establish a repayment agreement. Ultimately, the landlord chose to apply the duplicate payment of $7,700 towards future rents for the applicable tenant. During FY2023, Charles County identified the duplicate check and promptly requested the return of duplicate payment of $7,700 from SMTCCAC. During a program file audit by Charles County, it was determined that a duplicate expenditure included in the program cost was deemed unallowable. In FY2022, SMTCCAC paid $31,800 to a landlord who had already received payment from another participating ERAP agency. Despite notifications from SMTCCAC, the landlord has not/was not willing to return the duplicate funds to SMCTTAC. Charles County has notified SMTCCAC on numerous occasions about the need to reimburse the County for the duplicated funds. Once the funds are received, Charles County will return the monies to the State of Maryland. In March of 2023, the County also sent an invoice of $31,800 requesting SMTCCAC to return the $31,800. Questioned Costs: $7,700 ? duplicate payment made to a landlord for a rental assistance claim selected for testing. $31,800 ? duplicate payment made to a landlord for a rental assistance claim selected for testing. Recommendation: We recommend that SMTCCAC implement effective controls to prevent duplicate payments. Additionally, we recommend that SMTCCAC consistently verify the shared document used among participating ERAP agencies in Charles County to ensure that a claim has not been applied for and paid by other agencies. Views of Responsible Officials and Planned Corrective Actions: See Corrective Action Plans section.

View Audit 32240 Questioned Costs: $1

Finding 32083 (2022-005)

Significant Deficiency 2022

Southern Maryland Tri-County Community Action Committee, Inc.

MD

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.501

Finding Reference: 2022-005 Federal Agency: Department of Health and Human Services Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: Impacts All Federal...

Finding Reference: 2022-005 Federal Agency: Department of Health and Human Services Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: Impacts All Federal Award Programs Grant Award: Various Condition/Context: The single audit report was not submitted to the Office Management and Budget in accordance with the reporting requirement. Criteria: COSO/Internal Control Framework defines control activities as ?policies and procedures that help ensures management?s directives are carried out? This would include preparation of the Schedule of Expenditures of Federal Awards and the related Data Collection Form in a timely manner. Uniform Guidance 2 CFR 200.501 states that the audit shall be completed, and the data collection form shall be submitted within the earlier of 30 days after the receipt of the auditor?s report, or nine months after the end of the audit period. Accordingly, audits for fiscal years ending June 30, 2022 would be due on March 31, 2023. Cause: The single audit report was not submitted due to delays in year-end closing entries, schedules, and reconciliations. Effect: As a result of the finding, SMTCCAC did not provide required information to its federal oversight agency in a timely manner. Questioned Costs: None Recommendation: We believe that the year-end closing process could proceed in a timely manner by adhering to a closing schedule and maintaining timely account reconciliations. Progress should be monitored by management to determine that due dates are being met and required reports are submitted to regulatory agencies within the compliance time frame. Views of Responsible Officials and Planned Corrective Actions: See Corrective Action Plans section.

View Audit 32240

Finding 32082 (2022-001)

Significant Deficiency 2022

The Church Home of the Protestant Episcopal Church in the City of Roch

NY

Questioned Costs Reporting Material Weakness

Cause The Home included certain eligible expenses in its Provider Relief Fund reports due to evolving guidance and availability of funding streams at the time the reporting was due for the year ended December 31, 2021, at which time the Home was not pursuing reimbursement for these eligible expenses...

Cause The Home included certain eligible expenses in its Provider Relief Fund reports due to evolving guidance and availability of funding streams at the time the reporting was due for the year ended December 31, 2021, at which time the Home was not pursuing reimbursement for these eligible expenses from the Federal Emergency Management Agency (FEMA). Upon further guidance and clarification of available funds, the Home ultimately pursued reimbursement of these eligible expenses through FEMA. Effect While the Home incurred more than sufficient eligible expenditures and lost revenues to exhibit that the Home?s funds were fully utilized, the expenses claimed for reimbursement through FEMA are, in part, duplicated with expenses claimed for PRF funding. Recommendation We recommend that the Home maintain documentation that ensures they incurred enough eligible expenditures above and beyond amounts claimed for FEMA funding and lost revenue to continue to qualify for the full amount of the PRF funding, even though the expenditures claimed on the PRF reports were also claimed for FEMA funding. Management?s Response If these expenses were not included in the claim for PRF funding, the Home would have been eligible to apply these applicable funds against its lost revenue for the period being reported.

View Audit 31459 Questioned Costs: $1

Finding 32077 (2022-002)

Significant Deficiency 2022

Trinity Valley Community College

TX

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding 2022-002: Information on the Federal Program: CFDA 84.268 - Federal Direct Student Loan. United States of Department of Education. Compliance Requirements: Disbursement to or on Behalf of Students Type of Finding: Significant deficiency. Criteria: Program requirements state that the institut...

Finding 2022-002: Information on the Federal Program: CFDA 84.268 - Federal Direct Student Loan. United States of Department of Education. Compliance Requirements: Disbursement to or on Behalf of Students Type of Finding: Significant deficiency. Criteria: Program requirements state that the institution may not disburse or deliver the first installment of Direct Loans to first-year undergraduates who are first time borrowers until 30 days after the student's first day of classes (34 CFR 668.164(1)(2)). Condition: For each student in the sample selection receiving direct loans, we reviewed the school's documentation to determine if the student was a first-year undergraduates who are first time borrowers to determine is the institution disburse the first installment of direct loans until 30 days after the first day of class. Questioned Costs: $0 Context: We identified one student who was not coded as first-year undergraduate who was a first-time borrower in the Colleague System when he should have. Thisbefore the 30 days required time frame. Effect or Potential Effect: Early distribution to first-year undergraduates who are first time borrowers' students who are subject to the 30-day delayed disbursement requirement. Cause: Internal control process failure. Repeat Finding: No. Recommendation: TVCC should develop and institute a sustainable internal control system for appropriate identification of first-year undergraduates who are first time borrowers. Explanation of Disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The student identified in this finding did not attend in the fall and when switching over to a spring summer loan, the student was coded incorrectly. The TVCC Financial Aid Office has updated our process in packaging students that start in the spring term and did not attend in the fall to include reviewing those students manually. The financial aid job aide has been updated to include a manual review of students that are being imported into Colleague and plan to begin in the Spring semester. At the time of the review, the financial aid counselor is responsible for assigning the correct attendance pattern to the student's financial aid file to, so the student is packaged with the correct loan disbursement code.

View Audit 27745

Corrective Action Plans

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