Corrective Action Plans

Finding 565527 (2024-006)

Significant Deficiency 2024

PA

Student Financial Aid Subrecipient Monitoring Allowable Costs / Cost Principles

The finding from Section III – 2024-006 General Ledger System Condition: The District did not track the federal expenditures within the general ledger system, or if they were, the business office was unaware of the process and was not using the correct expenditures to claim as eligible expenditures...

The finding from Section III – 2024-006 General Ledger System Condition: The District did not track the federal expenditures within the general ledger system, or if they were, the business office was unaware of the process and was not using the correct expenditures to claim as eligible expenditures. Views of Responsible Officials and Planned Corrective Actions: Southern Fulton School District has hired a Certified Public Accountant (CPA) as the Chief Financial Officer (CFO) as of 4/1/2025 who will be responsible for ensuring that the general ledger system is utilized to track all federal expenditures.

View Audit 359322

Finding 565524 (2024-005)

Significant Deficiency 2024

Southern Fulton School District

PA

Student Financial Aid Subrecipient Monitoring Reporting

The finding from Section III – 2024-005 Reporting Requirements Condition: The District did not file the Title 1, Title 2, and Title 4 Reconciliation of Cash on Hand Quarterly Reports for March 2024 and June 2024.Additionally, the Final Expenditure Reports for Title 1, Title 2, and Title 4 were not ...

The finding from Section III – 2024-005 Reporting Requirements Condition: The District did not file the Title 1, Title 2, and Title 4 Reconciliation of Cash on Hand Quarterly Reports for March 2024 and June 2024.Additionally, the Final Expenditure Reports for Title 1, Title 2, and Title 4 were not filed by the required date. Views of Responsible Officials and Planned Corrective Actions: Southern Fulton School District has hired a Certified Public Accountant (CPA) as the Chief Financial Officer (CFO) as of 4/1/2025 who will be responsible for ensuring all Title reports are filed timely and by the deadlines.

View Audit 359322

Finding 565505 (2024-001)

Material Weakness 2024

Washington County, Fl

FL

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Finding – Adequate controls were not in place to provide for proper review of covered transactions for suspension and debarment. Covered transactions, over $25,000 paid with grant funding were not reviewed for suspension and debarment. Management Response – The County will implement additional cont...

Finding – Adequate controls were not in place to provide for proper review of covered transactions for suspension and debarment. Covered transactions, over $25,000 paid with grant funding were not reviewed for suspension and debarment. Management Response – The County will implement additional controls to ensure there is evidence of review of covered transactions over $25,000 for suspension and debarment prior to payment. Johnnie Pettis, Deputy Clerk will be responsible for the corrective action and anticipates completion of corrective action will be taken before September 30, 2025. Effective date of completion: within the fiscal year ending September 30, 2025

View Audit 359293

Finding 565485 (2024-038)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

MASSACHUSETTS EMERGENCY MANAGEMENT AGENCY 2024-038 Disaster Grants – Public Assistance (Presidentially Declared Disasters), COVID-19 - Disaster Grants – Public Assistance (Presidentially Declared Disasters) - Assistance Listing No. 97.036 Recommendation: We recommend the Department review and enhanc...

MASSACHUSETTS EMERGENCY MANAGEMENT AGENCY 2024-038 Disaster Grants – Public Assistance (Presidentially Declared Disasters), COVID-19 - Disaster Grants – Public Assistance (Presidentially Declared Disasters) - Assistance Listing No. 97.036 Recommendation: We recommend the Department review and enhance its procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: MEMA is recognizing the importance of documentation and internal controls. This current fiscal year an Internal Control Group was formed to review, create and overhaul what is needed or needed to be updated. The team primary stakeholders is made up of the CFO, Legal Counsel, Assistant Director for Recovery and Mitigation and Emergency Management Grants Supervisor. We are making the completion of updated Policies and Procedures a priority to address the findings such as the ones being pointed out as a critical piece to the success of the agency going forward. Name(s) of the contact person(s) responsible for corrective action: Randall Lui Planned completion date for corrective action plan: End of the Federal Fiscal Year 9/30/2025

View Audit 359283

Finding 565484 (2024-037)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

DEPARTMENT OF PUBLIC HEALTH 2024-037 Opioid-STR - Assistance Listing No. 93.788 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit year. It should establish procedures and internal controls to ensure that all required subawards are ...

DEPARTMENT OF PUBLIC HEALTH 2024-037 Opioid-STR - Assistance Listing No. 93.788 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit year. It should establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: All subrecipient FFATA information will be batched and uploaded to FSRS within 30 days of execution of subcontracts. Each month the FFATA submission receipt and all additional records pertaining to the upload will be saved. The internal Fiscal Compliance Auditor will review FFATA monthly submissions for compliance. Uploads will be made monthly by The Grants team. The Grants team at BSAS has created a Standard Operating Procedure (SOP) to make sure this process is repeated every month. Name(s) of the contact person(s) responsible for corrective action: Windy Senecharles Planned completion date for corrective action plan: July 1, 2025

View Audit 359283

Finding 565483 (2024-036)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

DEPARTMENT OF PUBLIC HEALTH, EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2024-036 Opioid-STR - Assistance Listing No. 93.788 Recommendation: We recommend the Department complete its corrective action plan from the prior year. It should ensure its internal controls and procedures are sufficie...

DEPARTMENT OF PUBLIC HEALTH, EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2024-036 Opioid-STR - Assistance Listing No. 93.788 Recommendation: We recommend the Department complete its corrective action plan from the prior year. It should ensure its internal controls and procedures are sufficient to ensure that required information is included in its subawards. Action taken in response to finding: A task has been added to our tracking system prompting contract managers to add FAIN and Grant Award Date information to an attachment to the Standard Contract Form. The DPH bureaus have consistently added this information to contract packages since this enhancement to our system was introduced. Name(s) of the contact person(s) responsible for corrective action: Windy Senecharles Planned completion date for corrective action plan: December 31, 2025

View Audit 359283

Finding 565467 (2024-031)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF EARLY EDUCATION AND CARE 2024-031 CCDF Cluster - Assistance Listing No. 93.575, 93.596 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the mont...

DEPARTMENT OF EARLY EDUCATION AND CARE 2024-031 CCDF Cluster - Assistance Listing No. 93.575, 93.596 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: EEC developed and implemented new policies and procedures that detail the FFATA reporting requirements, notification process, and control environment, including the data sources, in September of 2022. EEC did not implement the procedures necessary to ensure the report is submitted to SAM.gov in a timely manner as required. Applicable Accounting, Contracts, and Budget staff will be trained on these policies and procedures. Name(s) of the contact person(s) responsible for corrective action: Eric Hansson, Chief Financial Officer/CFO and Acting Chief Operating Officer/COO Planned completion date for corrective action plan: October 1, 2025

View Audit 359283

Finding 565466 (2024-030)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2024-030 Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Recommendation: We recommend the Department complete its corrective action plan from the prior year. It should ensure its internal controls and procedures are sufficient to ...

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2024-030 Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Recommendation: We recommend the Department complete its corrective action plan from the prior year. It should ensure its internal controls and procedures are sufficient to ensure that required information is included in its subawards. Action taken in response to finding: The Executive Office of Housing and Livable Communities (EOHLC), which was formerly the Department of Housing and Community Development (DHCD or Department), has implemented the recommended measures and will continue them going forward. EOHLC has reviewed their internal controls and procedures and is committed to making any enhancements that are necessary to ensure that required information is included in its subawards. EOHLC notes that the Federal Award Identification Number (FAIN) and the Federal Award Date are included in the HHS award notices and other HHS guidance, which EOHLC incorporates by reference into its LIHEAP subaward contracts with its subrecipients. In an effort to ensure compliance with these requirements going forward, EOHLC has included a direct reference to the FAIN and the Federal Award Date in its LIHEAP subaward contracts with its subrecipients, beginning with its FFY 2025 LIHEAP contracts. Name(s) of the contact person(s) responsible for corrective action: Edward Kiely Planned completion date for corrective action plan: October 1, 2024

View Audit 359283

Finding 565464 (2024-028)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2024-028 Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Recommendation: We recommend the Department review and enhance its procedures and internal controls to ensure that all required subawards are reported timely and accurately ...

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2024-028 Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Recommendation: We recommend the Department review and enhance its procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: The Executive Office of Housing and Livable Communities (EOHLC), which was formerly the Department of Housing and Community Development (DHCD or Department), has implemented the recommended measures and will continue them going forward. As a result of the original finding, 2022-018, EOHLC had previously put policies and procedures in place to ensure that all required subawards are reported timely and accurately to FSRS, and the Federal Funding Accountability and Transparency Act (FFATA) reports are reported timely and accurately. EOHLC’s FFATA report procedure was developed in September of 2023 and submitted on November 20, 2023. EOHLC notes that policies and procedures have already been put in place to remedy this issue. Name(s) of the contact person(s) responsible for corrective action: Frederique P. Phanor Planned completion date for corrective action plan: FFATA report procedure developed September 12, 2023 and LIHEAP submitted November 20, 2023

View Audit 359283

Finding 565457 (2024-022)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

DEPARTMENT OF PUBLIC HEALTH 2024-022 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend the Department review and enhance procedures and internal controls to...

DEPARTMENT OF PUBLIC HEALTH 2024-022 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend the Department review and enhance procedures and internal controls to ensure that required information is included in its subawards. Action taken in response to finding: The Bureau of Infectious Disease and Laboratory Sciences (BIDLS) will put in place starting August 1, 2025, a process where subawards are notified of the required information on subaward agreements or other sufficiently documented communication most notably to now include the additional information of the following: Federal Award Identification Number (FAIN) Federal Award Date Name(s) of the contact person(s) responsible for corrective action: Cheryl Bernard-Dort, Director of Administration and Finance, BIDLS Planned completion date for corrective action plan: 9/30/25

View Audit 359283

Finding 565453 (2024-020)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2024-020 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend the Department establish procedures and internal controls to ensure t...

DEPARTMENT OF PUBLIC HEALTH 2024-020 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend the Department establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: The Bureau of Infectious Disease and Laboratory Sciences (BIDLS) will put in place starting August 1, 2025 a process to review obligations for subawards under Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323, to identify subawards that fall under the rules set forth by Federal Funding Accountability and Transparency Act (FFATA) and report the appropriate obligations to FSRS according to the above-mentioned recommendations. Name(s) of the contact person(s) responsible for corrective action: Cheryl Bernard-Dort, Director of Administration and Finance, BIDLS Planned completion date for corrective action plan: 9/30/25

View Audit 359283

Finding 565451 (2024-019)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2024-019 Immunization Cooperative Agreements, COVID-19 - Immunization Cooperative Agreements - Assistance Listing No. 93.268 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit. It should establish procedu...

DEPARTMENT OF PUBLIC HEALTH 2024-019 Immunization Cooperative Agreements, COVID-19 - Immunization Cooperative Agreements - Assistance Listing No. 93.268 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit. It should establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to the FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: The Bureau of Infectious Disease and Laboratory Sciences (BIDLS) will put in place starting August 1, 2025 a process to review obligations for subawards under Immunization, Assistance Listing No. 93.268 to identify subawards that fall under the rules set forth by Federal Funding Accountability and Transparency Act (FFATA) and report the appropriate obligations to FSRS according to the above-mentioned recommendations. Name(s) of the contact person(s) responsible for corrective action: Cheryl Bernard-Dort, Director of Administration and Finance, BIDLS Planned completion date for corrective action plan: 9/30/25

View Audit 359283

Finding 565448 (2024-018)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-018 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: The Department should review and enhance internal controls and procedures to ensure that it obtains subrecipients’ unique entity identifiers and that all required information is i...

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-018 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: The Department should review and enhance internal controls and procedures to ensure that it obtains subrecipients’ unique entity identifiers and that all required information is included in all subaward agreements. Action taken in response to finding: AGE establishes contracts in accordance with MA Comptroller guidelines, which do not require the specified unique entity identifiers. However, in accordance with Federal Guidance, AGE will update all entries related to subrecipients to capture this information going forward. This requirement will be added to AGE’s internal control plan, specifically the section on federal grants management and compliance. Name(s) of the contact person(s) responsible for corrective action: Sheila Tunney, CFO Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565442 (2024-016)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-016 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the...

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-016 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: AGE has developed a form to attach to all relevant contracts to capture required reporting requirements and will implement a calendar of reporting deadlines to the AGE internal control plan, specifically the section regarding federal grants management. Name(s) of the contact person(s) responsible for corrective action: Sheila Tunney, CFO Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565436 (2024-014)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-014 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: We recommend the Department review and enhance internal controls and procedures to ensure that required information is included in its subawards. Action taken in ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-014 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: We recommend the Department review and enhance internal controls and procedures to ensure that required information is included in its subawards. Action taken in response to finding: The MassHire Department of Career Services (MHDCS) has reviewed, enhanced, and revised its documented internal controls and procedures to ensure that required award information is included and provided to its sub awardees through its formal submitted documentation. Name(s) of the contact person(s) responsible for corrective action: Michael Williams- Director of MHDCS Field Management & Oversight Planned completion date for corrective action plan: MHDCS partially implemented the above referenced internal control procedures on 12/30/22, prior to the end of Fiscal Year 2023. This procedure was fully implemented on 7/1/23 (the beginning of Fiscal Year ’24). MHDCS continues the process currently in FY 2025. MHDCS has revised all Financial/Fiscal related documentation (i.e., Budget Sheets, Contracts) for sub awardees to include the Federal Award Identification Number (FAIN) identifier, Federal award date as well as the Unique Entity Identifier (UEI) and the documented internal procedures as recommended through this audit finding. The FAIN and UEI numbers are consistently included on all budget sheets, contracts and contract modifications submitted to the EOLWD Budget and Finance department for processing and submission to each local entity or sub awardee.

View Audit 359283

Finding 565424 (2024-010)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-010 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved and subsequently reported timely to ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-010 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved and subsequently reported timely to FSRS no later than the end of the month following the month of issuance. Documentation of implemented controls should be readily available for auditors. Action taken in response to finding: EOLWD Finance has finalized a Standard Operating Procedure (SOP) to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. FFATA reporting as of FY 2025 has been transitioned to SAM.gov, providing a more streamlined and user-friendly platform for managing and tracking subaward reporting. To support timely submissions, a calendar reminder has been implemented to prompt monthly checks of reporting activity. The next phase of implementation will focus on expanding staff training to ensure more team members are equipped to complete FFATA reporting tasks accurately and efficiently. Ongoing monitoring will continue to ensure reporting remains timely and accurate, with periodic reviews conducted to assess performance and identify any needed updates to the SOP. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565414 (2024-007)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-007 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved, and subsequently timely submi...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-007 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved, and subsequently timely submitted to FSRS no later than the end of the month following the month of issuance. Documentation of implemented controls should be readily available for auditors. Action taken in response to finding: EOLWD Finance needs to update the Standard Operating Procedure (SOP) to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. FFATA reporting as of FY 2025 has been transitioned to SAM.gov, providing a more streamlined and user-friendly platform for managing and tracking subaward reporting. To support timely submissions, a calendar reminder has been implemented to prompt monthly checks of reporting activity. The next phase of implementation will focus on expanding staff training to ensure more team members are equipped to complete FFATA reporting tasks accurately and by establishing a more accurate subaward report. Ongoing monitoring will continue to ensure reporting remains timely and accurate, with periodic reviews conducted to assess performance and identify any needed updates to the SOP. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565412 (2024-004)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2024-004 Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation: The Department should review and enhance internal controls and procedures to ensure that required information is obtained prior to entering into a subrecipient ...

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2024-004 Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation: The Department should review and enhance internal controls and procedures to ensure that required information is obtained prior to entering into a subrecipient agreement. Action taken in response to finding: The Office for Food and Nutrition Programs (FNP) has confirmed the 19 CACFP subrecipients (out of 327) that either do not have a UEI or have one but has not registered it in SAM.gov. FNP will notify the subrecipients that their federal reimbursements will be put on hold until they take action and provide DESE with sufficient documentation that they have completed the tasks. Name(s) of the contact person(s) responsible for corrective action: Rob Leshin, Director, Food and Nutrition Programs Planned completion date for corrective action plan: July 15, 2025

View Audit 359283

Finding 565375 (2024-001)

None 2024

Umass Memorial Health Care, Inc.

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.318 § 200.324

2024-001 Procurement Cluster: Not applicable Grantor: Department of Health and Human Services (DHHS) Award Name: Congressionally Directed Spending Award Number: 6 CE1HS52894‐01‐04, 6 CE1HS52345‐01‐05 Award Year: FY2024 Assistance Listing Number: 93.493 Assistance Listing Title: Congressional Dire...

2024-001 Procurement Cluster: Not applicable Grantor: Department of Health and Human Services (DHHS) Award Name: Congressionally Directed Spending Award Number: 6 CE1HS52894‐01‐04, 6 CE1HS52345‐01‐05 Award Year: FY2024 Assistance Listing Number: 93.493 Assistance Listing Title: Congressional Directives Pass-through Entity: Not applicable In accordance with 2 CFR 200.318 the System must maintain procurement records of sufficient detail that include the rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price. For two of two of the auditors’ selections sufficient documentation was not retained from the time of procurement during fiscal year 2023 to demonstrate sole source justification or the competitive bidding process for these samples. For one mammography technology asset, documentation of sole source vendor justification was not documented and retained by the System following Policy HA-50-42, Capital Equipment Requests. For the second selection, while competitive bids were obtained, management did not adequately retain documentation to support the vendor ultimately selected for the selected hardware component and the other bids obtained. Management has reviewed the Capital Equipment Request policy and the related capital request process and will reinforce the need to adhere to existing policies and the importance of retaining appropriate documentation during fiscal year 2025. Primary responsibility of implementing the Corrective Action Plan for this finding rests with Brian Huggins, Senior Vice President of Finance, Corporate Controller, (508) 334-0252.

View Audit 359222

Finding 565372 (2024-002)

Significant Deficiency 2024

Summit County Colorado

CO

Eligibility Subrecipient Monitoring

Finding 2024-002 Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program CFDA # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: Our auditors, Eide Bailly, test...

Finding 2024-002 Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program CFDA # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: Our auditors, Eide Bailly, tested eligibility determination and controls over this process for sixty case files. They noted the following in our testing: • One instance of non-compliance in which the County did not complete the eligibility determination and approve/deny the case within 45 days and no notice of action was sent to the client within the required timeframe. • Two instances of non-compliance in which the County did not ensure removal from the Medicaid program due to cases being ineligible because of over income or being undocumented. Responsible Individuals: Joanne Sprouse, Human Services Director Corrective Action Plan: Summit County Human Services has successfully retrained all case managers on application processing protocols, utilizing state-approved training modules administered through the Staff Development Department. Summit County Human Services strictly follows state-mandated guidelines for processing Medical Assistance applications and ensures that all cases are approved or denied within the 45-day timeframe established by state regulations. To enhance the accuracy of eligibility determinations for all household members, case managers will also complete the "Case Wrap-Up Training" through CoLearn, an online training platform developed by the State's Staff Development Department. Completion of this training ensures that eligibility determinations are accurate, and that appropriate client correspondence is issued. In instances where eligibility errors are identified in Medicaid applications submitted via Connect for Health Colorado, a third-party agency operating independently from the county, Summit County will notify the agency within 24 hours. While such errors fall outside the county's control, the county is committed to promptly communicating corrections to ensure accurate application outcomes. Anticipated Completion Date: Ongoing

View Audit 359213

Finding 565370 (2024-001)

Significant Deficiency 2024

Seattle Children's Hospital

WA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.320

FINDING 2024-001: The entity did not have a control in place to review cost transfers to federal awards to ensure the entity followed the appropriate procurement policies for these costs. Without adequate controls over cost transfers, there is an increased risk of non-compliance with procurement ...

FINDING 2024-001: The entity did not have a control in place to review cost transfers to federal awards to ensure the entity followed the appropriate procurement policies for these costs. Without adequate controls over cost transfers, there is an increased risk of non-compliance with procurement policies. Corrective Action Plan: Management will design and implement a control to review cost transfers from non-federal awards to federal awards to ensure we follow our procurement policies. This will be achieved by adding a new step to the non-payroll cost transfer form that requires the requestor to include a copy of the Procurement authorization form if the procurement policies apply. The Procurement authorization form documents the process, rationale, and justification for procurements. If the purchase being transferred did not go through the appropriate procurement procedures at the time of purchase, then the transfer from the non-federal award to the federal award will not be allowed. Management will also provide additional training around procurement and our related policies and ensure staff involved in this area are aware of the new step embedded in the non-payroll cost transfer form. Remediation Date: July 2025

View Audit 359210 Questioned Costs: $1

Finding 565360 (2024-001)

Significant Deficiency 2024

Path

WA

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2024-001 PATH’s Response and Corrective Action Plan PATH has an established process for completing FFATA reporting in the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) in compliance with the requirements of the Federal Funding Accountability and Transp...

Finding 2024-001 PATH’s Response and Corrective Action Plan PATH has an established process for completing FFATA reporting in the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) in compliance with the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109‐282) (FFATA) that are codified in Title 2 U.S. Code of Federal Regulations, Part 170 ‐ Reporting Subaward and Executive Compensation Information. Although PATH complied with all other FFATA reporting requirements, reports for two subawards were not filed by the end of the month following the month in which PATH awarded these sub‐grants greater than or equal to $30,000. For the FFATA filings that were submitted late, the cause was that an employee new to PATH that year who assumed FFATA reporting did not realize her entries were not saving in the system correctly. This issue was discovered as part of a routine management review of PATH’s FFATA reporting. When the issue was discovered, management repeated the training on the Office of Grants and Contract’s (OGC) business process for FFATA reporting with that staff member and assigned another member of the team to review entries in the last week of each month, preventing future late filings. In 2025, OGC Management will add the following actions to the FFATA reporting business process strengthen to ensure all filings are submitted in a timely manner. Action Responsible staff member Due date Repeat training on OGC’s business process for FFATA reporting with the two OGC staff members responsible for FFATA reporting for PATH OGC Management June 30, 2025 Provide monthly report to OGC management by the last day of each month confirming timely reporting OGC Staff responsible for FFATA reporting Throughout 2025

View Audit 359204

Finding 565338 (2024-002)

Significant Deficiency 2024

Cook County, Illinios

IL

Subrecipient Monitoring § 200.303 § 200.332 § 200.339 § 200.521

To address this issue, the department will be taking the following corrective actions: 1. Training: Staff responsible for sub-recipient monitoring will complete updated training focused on federal Uniform Guidance requirements, as well as best practices for oversight and documentation. 2. Policy Rev...

To address this issue, the department will be taking the following corrective actions: 1. Training: Staff responsible for sub-recipient monitoring will complete updated training focused on federal Uniform Guidance requirements, as well as best practices for oversight and documentation. 2. Policy Review and Clarification: The department will review and revise its internal policies and procedures to align more closely with federal guidelines and institutional expectations. Clear protocols for sub-recipient monitoring activities will be disseminated to relevant personnel. 3. Ongoing Oversight: Upon implementation, the Department will conduct periodic reviews of sub-recipient monitoring activities to ensure compliance and for purposes of identifying any areas requiring further improvement. These actions are intended to strengthen compliance efforts and prevent similar issues in the future. Party(ies) responsible for overseeing the corrective action plan for the grant programs: - Nader Abusumayah, Chief Accountant, nader.abusumayah2@cookcountysao.org, 312.603.1840 - Nicole Kramer, Director of Programs and Development, nicole.kramer@cookcountysao.org, 312.603.1879 The department plans on completing the above corrective action on 8/30/2025

View Audit 359160

Finding 565337 (2024-001)

Significant Deficiency 2024

Cook County, Illinios

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.208 § 200.305

To address the identified non-compliance with timely subrecipient payments, the Cook County State’s Attorney Ofﬁce has implemented an internal invoice submission form designed to streamline and formalize the invoice processing workflow. This form is now utilized by all business managers and program ...

To address the identified non-compliance with timely subrecipient payments, the Cook County State’s Attorney Ofﬁce has implemented an internal invoice submission form designed to streamline and formalize the invoice processing workflow. This form is now utilized by all business managers and program managers, who have been trained and granted functional access to ensure consistent and accurate usage. Additionally, a dedicated SharePoint site has been established to manage and monitor the invoice submission process. This platform allows for real-time tracking of invoice numbers, amounts, vendor names, and payment statuses, thereby enhancing transparency and accountability. These measures collectively aim to strengthen internal controls, improve communication among parties involved, and ensure compliance with federal cash management requirements moving forward. Party(ies) responsible for overseeing the corrective action plan for the grant programs: - Nader Abusumayah, Chief Accountant, nader.abusumayah2@cookcountysao.org, 312.603.1840 The department plans on completing the above corrective action on 6/1/2025.

View Audit 359160

Finding 565322 (2024-001)

Material Weakness 2024

Agency for Substance Abuse Prevention, Inc.

AL

Internal Control / Segregation of Duties Reporting Subrecipient Monitoring

Management of The Agency for Substance Abuse Prevention, Inc. hereby submits the following corrective action plan in response to the single audit findings for the fiscal year ending September 30, 2024: Finding 2024-001 – Segregation of Duties: Description of Finding: The auditor found that duties ...

Management of The Agency for Substance Abuse Prevention, Inc. hereby submits the following corrective action plan in response to the single audit findings for the fiscal year ending September 30, 2024: Finding 2024-001 – Segregation of Duties: Description of Finding: The auditor found that duties were not segregated in a number of areas where small adjustments to the policies of the Entity could help to further facilitate this important control. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective Action: Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring approvals for all transactions.

View Audit 359146

Corrective Action Plans

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